As the first disease-modifying therapies for Alzheimer's reach patients, a critical question emerges: do their clinical benefits justify their price tags? The answer, according to a new systematic review, is a clear no — at least at pricing levels currently in place. This has direct implications for how broadly these medications will be accessed, covered by insurers, and integrated into standard care.
Analyzing 23 studies across four major databases and adhering to both CHEERS and PRISMA reporting standards, researchers evaluated the incremental cost-effectiveness of all FDA-approved Alzheimer's neurotherapeutics. Traditional agents — memantine, donepezil, rivastigmine, and galantamine — fared well. Memantine was cost-effective in every study at the conventional $100,000-per-quality-adjusted-life-year (QALY) willingness-to-pay threshold, while more than half of studies confirmed cost-effectiveness for the three cholinesterase inhibitors as a class. In sharp contrast, the anti-amyloid monoclonal antibodies aducanumab, lecanemab, and donanemab failed to meet cost-effectiveness benchmarks in any study at that same threshold. Only at a $150,000/QALY threshold did value-based pricing estimates for these biologics emerge — and even then, those estimates fell below $5,000 annually, far below current list prices.
This systematic review crystallizes a growing tension in Alzheimer's pharmacoeconomics: treatments that work clinically do not automatically deliver proportionate value at market prices. The anti-amyloid antibodies represent genuine mechanistic advances — targeting beta-amyloid plaques rather than merely managing symptoms — but their real-world benefit sizes, measured in CDR-SB or MMSE units, remain modest in absolute terms. With annual costs historically exceeding $20,000–$26,000 for lecanemab and donanemab, the gap between clinical benefit and economic value is substantial. The 43% industry-funding rate among included studies is a notable limitation that could bias estimates toward more favorable conclusions, yet the anti-amyloid antibodies still failed. For health systems and payers navigating coverage decisions, this evidence base strongly favors prioritizing generic cognitive agents while pressing for value-based pricing negotiations on the newer biologics.