Key result
Adding lecanemab to apixaban in patients 65-74 years with early Alzheimer's and atrial fibrillation yielded similar QALMs (13.2) but increased intracranial hemorrhages (1,990 vs 400 per 100,000).
Why the study?
Lecanemab slows cognitive decline in early Alzheimer disease but appears to increase intracranial hemorrhage risk, motivating an evaluation of the benefits and harms of co-prescribing lecanemab and anticoagulants in patients with AF and early AD.
Does co-prescribing lecanemab and apixaban improve quality-adjusted life months compared to apixaban alone in older adults with atrial fibrillation and early Alzheimer's disease?
Does co-prescribing lecanemab and apixaban improve quality-adjusted life months compared to apixaban alone in older adults with atrial fibrillation and early Alzheimer's disease?
Microsimulation modeling suggests that for patients ≥75 years with early Alzheimer's disease and atrial fibrillation, anticoagulation alone is preferred over adding lecanemab due to increased intracranial hemorrhage and mortality risks.
No QALM gain yet higher ICH with added lecanemab in modeled 65-74s; leaves open refined risk estimates before trials or practice change.
Background: Lecanemab slows cognitive decline among people with early Alzheimer's disease (early AD) but appears to increase the risk of intracranial hemorrhages (ICHs), including anticoagulant-related ICHs. Objective: To examine the benefits and harms of co-prescribing lecanemab and anticoagulants in people with atrial fibrillation (AF) experiencing early AD. Design: Microsimulation model to compare four treatment strategies. Using inputs from the literature, we modeled increased ICH risk with lecanemab (2.02-fold), apixaban (1.84-fold), and lecanemab/apixaban interaction (2.67-fold). We assigned quality-of-life estimates and increased mortality risk with cognitive decline, stroke, and ICH. Data Sources: Clinical trials, observational cohorts. Target Population: People 65-90 years with AF and early AD. Time Horizon: 18-month. Intervention: ), neither. Outcome Measures: ICH, ischemic stroke, cognitive decline, quality-adjusted life months (QALMs), and survival, age-stratified. Results of Base Case: alone would always be preferred. Results of Sensitivity Analysis: Results are sensitive to lecanemab-anticoagulant interaction on ICH, baseline ICH risk, and lecanemab's effect on cognition. Limitations: Significant parameter uncertainty; treatment burden and costs were not modeled. Conclusions: Model-based results support anticoagulants alone as the preferred strategy for people ≥75 years with early AD and AF. There was greater equipoise across treatment strategies for persons 65-74 years, for whom improved estimates of the ICH risk and lecanemab-anticoagulant interaction are critical to identifying the preferred strategy. Primary Funding Source: National Institute on Aging/National Institutes of Health (K76AG074919, P30AG062421, U01AG076478, and R01AG069575).
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Shah et al. (2025) studied Early Alzheimer's disease and atrial fibrillation (n=100,000). Apixaban and lecanemab vs. Apixaban alone was evaluated on Quality-adjusted life months (QALMs) over 18 months for persons aged 65-74 years. Adding lecanemab to apixaban in patients 65-74 years with early Alzheimer's and atrial fibrillation yielded similar QALMs (13.2) but increased intracranial hemorrhages (1,990 vs 400 per 100,000).
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