Anti-amyloid therapies and the transformation of Alzheimer's care pathways: early lessons from the frontline

The introduction of anti-amyloid monoclonal antibodies marks a major shift in Alzheimer's disease (AD) care, moving treatment toward biological modification and reshaping diagnostic and organizational models. At the Center for Alzheimer's and Related Diseases (CARD), IRCCS San Raffaele Hospital (Milan, Italy), among the first European tertiary centers to initiate both lecanemab and donanemab, we developed a structured fast-track pathway to support timely and safe access to therapy. Our early real-world experience highlights three critical domains. First, patient selection requires integration of cognitive, functional, and biological data, moving beyond rigid global score thresholds. Second, safety monitoring must balance ARIA risk with real-world feasibility through risk-adapted MRI surveillance. Third, effective implementation depends on transparent communication and continuous shared decision-making, particularly when benefit is uncertain or safety events occur. These elements underscore that the impact of disease-modifying therapies will depend not only on pharmacology, but on coordinated care models supported by real-world registries.