Improving Alzheimer Disease Care Through Earlier Diagnosis and Team-Based Support

As Alzheimer disease treatment enters a new era marked by earlier diagnosis and disease-modifying therapies, pharmacists are becoming increasingly important members of the care team. In this interview, Josean Gonzalez, PharmD, BCPP, a clinical pharmacy specialist in internal medicine at Baptist Health South Florida, discusses the evolving Alzheimer disease landscape, including antiamyloid monoclonal antibodies, emerging diagnostic biomarkers, and the growing opportunities for pharmacists to support patients and caregivers through medication optimization, safety monitoring, and coordinated multidisciplinary care.

Pharmacy Times: Can you introduce yourself and describe your role?

Josean Gonzalez, PharmD, BCPP: Yes, of course, my name is Josean Gonzalez, and I am currently a clinical pharmacy specialist in internal medicine here at Baptist Hospital of Miami.

And a little bit about our role: We do have a variety of things that we do, but I would say the main roles are being involved in participating in medical rounds, with the attending physicians, with medical residents, also with pharmacy residents and students. And in there, we participate together, and we provide knowledge about medications, helping them with the decision-making of our plans, of our patients that we round within our floors, right?

In addition to that, we also complete a number of different clinical consults. So, for example, we monitor anticoagulation, such as warfarins. We also monitor parenteral nutrition, such as TPNs. And then we also complete clinical consults for monitoring vancomycin therapies as well.

And then finally, I would say some of the other roles that we have are working on different projects and, and initiatives to improve or enhance our pharmacy clinical, practice in our, in our hospital here. So, these could be things like in-service presentations or medication use evaluation reviews and things of that nature.

Pharmacy Times: From your perspective, how has the conversation around Alzheimer disease changed over the past several years?

Gonzalez: That's actually a very good question, specifically because we're talking about Alzheimer disease, and I do believe that the conversation in this condition has shifted drastically. We've gone from looking more mostly the symptom management to now looking further down to things like early diagnosis or different biomarkers for diagnosing as well, and even some disease-modifying agents, right? Now, historically, the pharmacological options have been more limited, right? We've been more limited to symptomatic therapies, for example, the cholinesterase inhibitors that we have, right? Donepezil (Aricept; Eisai), rivastigmine (Exelon; Novartis),galantamine (Razadyne; Janssen Pharmaceuticals), and memantine (Namenda; AbbVie, Merz Pharmaceuticals), right? And these medications help with some of the cognition, the function, and some of the behavioral aspects in some patients, but they do not change the underlying disease process, right?

And now, on the other hand, with some of these new agents, what we call the antiamyloid monoclonal antibodies, the field, I feel like it has entered a different phase. Now, I would say that these antiamyloid therapies, they've created some more hope, but I will also say that they've created some more complexity too because they do require careful patient selection, amyloid confirmations, things like MRI monitoring, and of course, the shared decision-making. But I would say that unlike traditional therapies, which are primarily targeting that symptomatic benefit, these antiamyloid medications are among the first treatment agents that have shown to target that underlying disease process and modestly slow that clinical decline in selected patients in Alzheimer disease.

Pharmacy Times: The Alzheimer treatment landscape has evolved significantly. What are some of the most important developments pharmacists should be aware of?

Gonzalez: Yes, so continuing on the medications I was, I was mentioning before, these antiamyloid therapies, I do believe that these are one of the biggest that pharmacists should be aware of since they are the newer developments and we have 2 agents available right now. We have lecanemab (Leqembi; Eisai, Biogen), which was FDA-approved in 2023, and we also have donanemab (Kisulna; Eli Lilly), and this one was approved by the FDA 1 year later in 2024.

These are monoclonal antibodies that are able to target the amyloid beta protein in the brain, and they do this, to reduce that amyloid burden, which is believed to be one of the key driving factors of Alzheimer disease. Now, they bind to these plaques, and they help the immune system clear them from the brain. But in addition to knowing their names and how they work, I would also say that pharmacists should know the role of these medications because these agents are intended and indicated right now only for the early stages of Alzheimer disease, not so much the later stages, right? So making sure to know that distinction.

And also, as pharmacists, of course, we should be able to recognize and know the [adverse] effects (AEs) that medications have overall. So, with these medications, I would definitely say that the big one is what we call ARIA, and it's a big [AE] that, of course can be severe concerning if it does occur, and it's, it refers to amyloid-related imaging abnormalities. This is basically [an AE] that patients could develop either swelling in the brain or bleeding in the brain, so making sure, as pharmacists, knowing that

complication and knowing how to counsel patients and caregivers regarding this.

Now, another important development that I would say pharmacists should be aware of is also that growing or the general growth of different biomarkers for diagnosis because this also helps identify patients that can be candidates for these disease-modifying therapies, right? We have new amyloid PET scans or we have, cerebrospinal fluid testings, and even there [are]…these emerging blood-based biomarkers, that will of course make Alzheimer evaluation much more accessible in the future. And one example could be even a tau protein that has been studied recently. It's a protein that accumulates inside the neurons, and it also thought to be linked to Alzheimer disease.

So, these types of things are definitely new developments and very interesting and something that us pharmacists should be aware of.

Pharmacy Times: How is Baptist Health South Florida involved in Alzheimer disease care and management?

Gonzalez: Yeah. So actually, Baptist is, is very involved in Alzheimer disease care. In one of our sites, we actually have a comprehensive memory care program, and this is led by specialists in dementia and cognitive disorders. We're also able to provide access to these newer disease-modifying medications…the antiamyloid monoclonal antibodies. And these treatments can be administered through our Baptist network of infusion centers that we have across South Florida. So of course, it helps out improving that access and convenience for patients, which is, which is awesome.

Also, I would say that delivering these therapies, it takes a village, right? It takes a group of a multidisciplinary approach…this involves neurologists, pharmacists, nurses, and even imaging teams to make sure that we're selecting the proper patients and completing the proper monitoring that these medications need. Now, I will also say that, in addition to diagnosis and treatment, the program also provides, imaging service, right? We provide social work support, caregiver resources, and just support groups in general. And I would say that's very, very important, not for only for the patient, but the caregivers as well.

And then finally, I would say we're excited about some new, ongoing studies that we're having here at Baptist. Baptist is also involved in the clinical trial area, right? There have been ongoing new studies, for example, looking at new approaches like ultrasound, which, or like more like focused ultrasound, which may help improve amyloid clearance. We've also been involved in newer studies looking at stem cell-based therapies and also even microdose whole brain radiation therapies.

So of course, while many of these approaches are still being investigated, it is exciting to see that Baptist is contributing not only to the delivery of these medications, but also the development of future options.

Pharmacy Times: What are some of the biggest barriers patients with Alzheimer’s disease still face in accessing care or treatment, and how can health systems and pharmacists offer their support?

Gonzalez: Yes, this is also a good question and an important one in my opinion because unfortunately, Alzheimer disease patients, they do face a number of barriers.

The first one that comes to mind, I would say, is timely diagnosis. A lot of times, many patients are diagnosed late in their condition, and at that point, symptoms may be more advanced. And I mentioned this, and this is important because, for example, these newer antiamyloid therapies, like I mentioned, they are intended for the early stages of the disease. And then, of course, also by the point of more advanced symptoms, it could be harder to slow down that decline.

Another barrier that I would say these patients face is just the general access to the diagnostic workup, right? Patients with Alzheimer disease, they may need cognitive evaluations, and more specifically towards these antiamyloid agents, amyloid confirmations, MRIs, specialist referrals, and then of course, access to those infusion centers. And that could be difficult for many patients depending on where they live, what kind of insurance they have, and even caregiver availability. So that's definitely a big barrier.

And now that I mentioned caregivers, that is also a big one that I [want to] emphasize. The caregiver burden, I feel like it's also a barrier, right? With this condition, sometimes the caregivers might experience a level of burden because it's not easy to help and take care of patients with Alzheimer disease. And they might find themselves repeating frequent things often or facing the commonly exhibited agitation and aggression that Alzheimer disease patients can present. So it's also hard for them. I feel like us pharmacists, we can also play a role in educating them as well and having a realistic expectation and having everyone on the same page. But I would say those are, big barriers that come to mind.

And as far as improving all these, I feel like health systems in general can help expand access to these diagnostic services, right? Increasing the availability of specialists that work in this area. And of course, access to these infusion centers as well. And not only transportation and all that, but also the cost in general.

And then us pharmacists, we can actually play a big role, too. There [are] a lot of things that we can do to help these patients. First of all, we can start by helping optimizing therapy, right? We can take a look at the medication regimen and see if there's any potential medication that might be worsening their cognitive status, maybe anticholinergic agents, benzos, CNS depressants that might be worsening cognition. So we could take a look at that and also reduce polypharmacy, right? We can also educate patients, not only them but caregivers, rgoing back to that burden, providing education as much as we can. And then of course, the monitoring safety of medication.

So ultimately, I would say reducing these barriers and simplifying the process for them as much as we can, it definitely makes a meaningful difference, not only for the patient, but for their families and their caregivers.

Pharmacy Times: Is there anything coming in the pipeline (eg, new treatments, therapeutic interventions, clinical trials) that you are particularly excited for?

Gonzalez: Yes, there's actually a few things that I'm excited for in terms of Alzheimer disease and the future.

The first one that I want to mention is the ongoing development of these blood-based biomarkers for diagnosis. I feel like if we can use this and expand this, it can make Alzheimer diagnosis much more accessible, and we can be able to help identify patients earlier. Now, also, these could be much less invasive, right? And potentially easier to implement in, like, a routine clinical practice compared to things that I mentioned earlier, like amyloid PET scans or the cerebral spinal fluid testing. So I'm definitely excited for that development.

Secondly, I would say just the continuous and ongoing development of these disease-modifying therapies. Because right now, yes, I've been mentioning a lot about the antiamyloids, but of course, they are primarily targeting amyloid plaques. But now researchers are going even further, and now they're starting to investigate other pathologies, too. Going back to that tau protein that I mentioned earlier, they are looking at this one as well. They're looking at neuroinflammation and other pathways involved in Alzheimer disease. So, it's a very interesting time that not only the treatment, but also the diagnostic process might change as well.

And then finally, in terms of studies, too, I'm excited because there's some ongoing studies that are evaluating these therapies, but even earlier in the disease, before any symptoms develop, which could include preclinical Alzheimer disease since the underlying pathology, it is thought to begin years before the actual cognitive decline becomes apparent. The earlier the intervention, you know, it might provide a better opportunity to help preserve the cognitive function for a longer period of time, perhaps. So I would say those are the things that I'm excited about overall.

Pharmacy Times: Any final or closing thoughts?

Gonzalez: No, nothing specifically. I would like to close out just by generally saying that, you know, Alzheimer disease care is, is changing drastically and rapidly. And these newer therapies, they do represent a meaningful progress for selected patients, of course. But on the other hand, too, us pharmacists, we can play a key role through many different things. I talked about education for patients and caregivers. I mentioned medication optimization, which is crucial, and then of course, safety monitoring for these patients and providing caregiver support and education to them as well.

So all those things, it's [going to] help out in the big picture of the patient. And in general, just that our goal should be to just provide and help the patient access the right medication at the right time, and then, of course, ensuring the proper safety and the proper coordinated care.