[Interview] Korea's 1st Alzheimer's antibody faces cost, access barriers

Professor Cho Han-na of Gangnam Severance Hospital said Korea’s first anti-amyloid Alzheimer’s drug is still out of reach for many patients because of cost, monitoring demands and limited access. (Courtesy of Gangnam Severance Hospital)

Leqembi (lecanemab), from Eisai and Biogen, reached the Korean market last year for people with mild cognitive impairment or mild dementia due to Alzheimer’s disease. The drug is meant to be used early, before decline becomes more advanced.

In practice, doctors say, many patients hit the same wall before treatment even begins: the drug is not reimbursed, the amyloid PET scan used to confirm eligibility is not reimbursed, and the MRI scans needed to watch for treatment-related brain swelling or bleeding add still more cost.

At Gangnam Severance Hospital, neurologist Cho Han-na said she has prescribed Leqembi to about 80 to 100 patients, a large number for one doctor. Even there, she estimated, fewer than 10 percent of patients who look like they could qualify actually end up starting treatment.

The biggest reason is cost, she said. The other is how hard it is to build treatment into a hospital system that still does not treat dementia as a high-priority condition in practice.

Leqembi targets amyloid beta, the protein that builds up in the brain in Alzheimer’s disease. It is meant to slow decline, not reverse damage that has already occurred. “If you say this drug makes patients better, that is not really true,” Cho said in an interview with Korea Biomedical Review. “The best outcome is not getting worse.”

That is also why time matters so much. The patients most likely to benefit are the ones still in the earlier phase of disease. Cho said those are often the same patients who get stopped first by cost.

At her hospital, she said, an amyloid PET scan usually costs around 1.2 million to 1.5 million won  (roughly $800 to $1,000) because it is not covered.

Once treatment starts, patients then need repeated MRI scans because anti-amyloid antibodies can cause amyloid-related imaging abnormalities (ARIA), a class of brain swelling and bleeding events that has become one of the main practical hurdles in real-world use.

Patients know that. Families know it too.

One woman in her mid-50s who started Leqembi last year said her hospital recommended the drug because she was still relatively young and still early in the disease.

She said she agreed because the alternative felt worse. “It’s dementia,” she said. “There’s no other way.”

Her treatment did not go smoothly. She developed repeated ARIA episodes, was given steroids, underwent follow-up MRI scans and eventually stopped.

One MRI bill alone topped 1.18 million won, according to medical receipts reviewed by Korea Biomedical Review during an interview.

Her daughter described the toll less as one bad event than as a chain of them -- more scans, more visits, more monitoring, more fear each time they tried again.

“Why does dementia keep falling down the priority list? I really don’t understand it,” Cho said. (Courtesy of Gangnam Severance Hospital)

Cho said many patients turn down treatment for exactly those reasons. Some cannot afford it. Some cannot manage the trips every two weeks. Some decide the side-effect risk is too much.

For patients who still want the drug, doctors then have to screen for who may be at higher risk of side effects, including people with prior microbleeds, stroke history, head injury or certain genetic risk factors. “Even if it is one out of 99, for the person it happens to, it is 100 percent,” Cho said.

She said the problem is sharper in younger-onset cases. Those patients do not always arrive with the classic complaint of memory loss. Some first present with depression, anxiety, behavior change or other symptoms that send them through other clinics before they reach a dementia specialist.

By the time they do, Cho said, they may already be past mild cognitive impairment and into dementia. Some still have children in their teens or 20s. If the government cannot cover everyone, she said, those younger patients should “at least” be included.

Cho’s complaints went beyond the drug price. She said two policy issues now matter most: reimbursement and dementia’s low standing in the severity system that shapes how tertiary hospitals allocate beds and resources.

She said clinicians have been asking the government to raise dementia’s severity level, but do not even know the basis for the current standard.

She also said the first few infusions require hours of observation, and that in her view some patients need admission early in treatment, which becomes harder if dementia is treated as lower-acuity than diseases that hospitals are pushed to prioritize.

Cho said Korea is willing to spend on dementia later, through caregivers, nursing homes and other long-term care, but is still hesitant to pay earlier, when treatment might help some patients stay independent longer.

She contrasted that with cancer, where drugs are more often reimbursed and hospitals face less ambiguity about priority.

That argument is now colliding with another one. Britain’s National Institute for Health and Care Excellence said this year that neither lecanemab (Leqembi) nor donanemab (Kisunla from Eli Lilly) should be offered routinely on the National Health Service because the benefit did not justify the total cost of the drugs, infusions and monitoring.

Korea has ended up in a different place: the drug is on the market, but many doctors say the patients who might want it most are still being filtered out by cost and logistics before treatment becomes routine.

Kim Ji-hye