The UK's medicines regulator, the Medicines and Healthcare products Regulatory Agency (MHRA), has approved lecanemab for use in Great Britain, marking a significant milestone in Alzheimer's disease treatment. However, the National Institute for Health and Care Excellence (NICE) has issued an interim decision deeming the drug not cost-effective for the NHS in England and Wales, effectively restricting access to private patients who can afford the estimated £20,000 annual cost.
The decision has sparked criticism from advocacy groups who argue it creates a two-tier healthcare system where only wealthy patients can access this potentially life-changing treatment.
How Lecanemab Works
Lecanemab, marketed under the brand name Leqembi by Japanese pharmaceutical company Eisai, is a disease-modifying treatment that targets the underlying pathology of Alzheimer's disease. The monoclonal antibody works with the body's immune system to reduce the accumulation of amyloid protein, clumps of which are widely believed to be a key driver of neurodegeneration in Alzheimer's.
In clinical trials, lecanemab demonstrated the ability to slow cognitive decline by approximately 27% in early-stage Alzheimer's patients over an 18-month period. The drug also showed promise in slowing quality of life deterioration by up to 56%. However, the treatment is not without risks, with notable side effects including brain swelling and bleeding.
NICE's Cost-Benefit Analysis
Helen Knight, director of medicines evaluation at NICE, explained the rationale behind the rejection: "Lecanemab provides on average four to six months' slowing in the rate of progression from mild to moderate Alzheimer's disease, but this is just not enough benefit to justify the additional cost to the NHS."
NICE cited significant expenses beyond the drug itself, including intensive monitoring requirements for side effects and the logistical burden of fortnightly hospital visits for intravenous administration.
Scotland's Pending Decision
While NICE's decision affects England and Wales, Scotland maintains its own independent review process through the Scottish Medicines Consortium (SMC). The SMC is still assessing lecanemab, and advocates are hopeful for a different outcome, noting that Scotland has previously diverged from NICE on expensive new treatments, including breakthrough cystic fibrosis medications.
Henry Simmons, Chief Executive of Alzheimer Scotland, has urged the SMC to "reach a positive decision" on lecanemab, framing access to the treatment as a human rights issue for people with early-stage Alzheimer's.
"Scotland has already led the way in developing brain health services through our partnership with Scottish Government and NHS Grampian in particular," Simmons stated. "This model fits entirely with the types of changes within the system that would be required to meet the needs of individuals eligible to receive this new drug."
Limited Eligibility and Practical Considerations
Experts emphasize that lecanemab would not be a universal treatment for all dementia patients. The drug is specifically indicated for people in the very early stages of Alzheimer's disease who meet strict eligibility criteria. In Scotland, this would represent a subset of the approximately 90,000 people living with dementia.
"While we understand this drug is not a silver bullet, it's probably the most important first step we can take on a journey towards an effective disease-modifying treatment," Simmons noted.
Advocacy Response
Alzheimer Scotland has strongly criticized NICE's interim decision as "incredibly short-sighted," arguing it focuses solely on financial cost-benefit analysis while failing to consider the human cost of the disease.
"The impact that lecanemab could have on the quality of life of someone with Alzheimer's is unquestionably worth the current stated costs," Simmons asserted. "It is unacceptable to reject a drug treatment simply because of challenges around securing early diagnosis or delivering it intravenously."
The organization plans to actively participate in NICE's consultation process on lecanemab while advocating for SMC approval in Scotland.
Healthcare System Implications
If approved in Scotland, implementing lecanemab treatment would require significant healthcare system adaptations, including enhanced early diagnosis capabilities and infrastructure for intravenous administration and monitoring. Advocates argue that Scotland's existing brain health services provide a foundation that could be expanded to support these requirements.
As stakeholders await the SMC's decision, the debate continues about how healthcare systems should value innovative treatments for devastating conditions like Alzheimer's disease, particularly when benefits may appear modest in statistical terms but could represent meaningful improvements in quality of life for patients and their families.
