A scientist looks at hypometabolic and hypoperfusion patterns in a patient with Alzheimer's at the Memory Centre at the Department of Readaptation and Geriatrics of the University Hospital in Geneva, Switzerland.Denis Balibouse/Reuters
It’s not enough for a drug to work. It has to work well, and provide value for money, especially if we’re going to fund the treatment from the public purse.
That’s the important message we should retain from the latest report from Canada’s Drug Agency, which recommended that public drug plans should not pay for a new medication that slows cognitive decline in early Alzheimer’s patients.
Some clinicians and patient groups saw the thumbs-down for public funding as a slap in the face.
After all, lecanemab is the first disease-modifying drug approved for treatment of Alzheimer’s in two decades. Monoclonal antibody treatments like this one, which clear amyloid plaque from the brain, are the greatest hope for slowing dementia that we’ve seen in a long time.
But, so far, they have not proven themselves ready for prime time. First, we saw the failure of aducanumab (brand name Aduhelm). And now lecanemab also gets a “meh” rating.
Quebec will not cover Health Canada-approved Alzheimer’s drug
In clinical trials, lecanemab made a difference, slowing the progression from mild to more serious symptoms by about five months over an 18-month period, and there are early indications in continued testing that the drug can stave off deterioration even longer.
But, as the CDA panel concluded, the “clinically meaningful benefit” remains unclear. And the benefits in slowing cognitive and functional decline that were seen came at tremendous cost.
The drug itself, lecanemab (brand name Leqembi), has a list price of US$26,500, and that’s just the tip of the iceberg.
The drug is aimed at a very specific population: those with mild cognitive impairment or mild dementia owing to Alzheimer’s.
It requires a phalanx of costly tests before and during use, including psychological and genetic testing to determine if a patient is eligible, complex intravenous administration of the drug itself, and frequent imaging tests. There are also rare but serious side effects, especially in those with a genetic predisposition to Alzheimer’s.
Lecanemab was approved by Health Canada in October, 2025, after a lengthy 2½-year review. About 50 other countries have already approved the drug, a reminder of how painfully slow our drug approval process is. (But that’s a topic for another day.)
Drugs are approved if they are safe, and provide at least as much benefit as existing treatments.
Not every drug that is approved is funded by public or private insurers. Nor should they be.
In Canada, we talk a lot about the costs of care, but not near enough about the value. If we’re going to fund a drug that costs $30,000 (and much more in ancillary costs), it should have a significant clinical impact.
What is Alzheimer’s disease, and what are the symptoms and treatments for the condition?
Lecanemab does not cure Alzheimer’s, nor does it reverse the disease, or bring back memories. It slightly delays the inevitable.
For some, an extra five months of relative good health is worth the cost.
There are currently nine people in Canada taking lecanemab, but they are paying for it out-of-pocket. Critics of the CDA recommendation argue this creates inequity – that only the wealthy can benefit from the treatment.
That is true, but that does not justify treating everyone eligible with public dollars.
Health spending in Canada reached $399-billion in 2025, with $53-billion spent on drugs. There will never be enough money to provide every possible treatment to every Canadian via medicare.
We have to make choices – tough choices – and they need to be guided by science and good policy, not emotion or wishful thinking.
One of the benefits of the media coverage of the lecanemab decision is that it has spurred more open discussion of the difficult dilemmas that come with limited health dollars.
Fundamentally: What do we fund, when, and why? How do we measure success of an intervention, and whether it provides value for money, individually and collectively?
With breakthroughs in genomics, proteomics, robotics, artificial intelligence, and more, treatments are becoming more targeted and individualized, and more costly.
Having some guiding principles for funding becomes more important than ever.
The other lesson from the lecanemab debate is that prescribing a drug is no longer just about the drug any more. We need an infrastructure of genetic testing, rapid imaging, infusion clinics, and more, and we can’t build it from scratch for every new drug.
There is an urgent need for an effective, inexpensive, easy-to-use drug for dementia (and many other conditions), and if, and when, they arrive, we have to be ready to administer and fund them.
But, until then, we need to continue saying: “Sorry, not good enough yet.”