19/02/2026
Alzheimer Antibody Therapy Rejected in Scotland
Why This Strengthens the Case for Prevention
The Scottish Medicines Consortium has declined to approve donanemab for use within NHS Scotland for early stage Alzheimer disease .
The decision affects people with mild cognitive impairment and mild dementia who have confirmed amyloid pathology. Although clinical trials showed statistically significant slowing of decline, the committee raised concerns about how meaningful that slowing would be in real world care, alongside safety and cost effectiveness considerations .
For many families this is disappointing.
At Cogmission Clinic in Edinburgh, we see this decision through a wider lens.
It reinforces something we have believed for years.
By the time someone qualifies for an antibody infusion, the disease process has already been unfolding for decades.
Understanding the Therapy
Donanemab is a monoclonal antibody that targets amyloid plaques in the brain. In the phase 3 TRAILBLAZER ALZ 2 trial, it slowed cognitive and functional decline over seventy six weeks compared with placebo .
Treatment involves intravenous infusions every four weeks, along with genetic testing and repeated MRI monitoring. Amyloid related imaging abnormalities were common. Brain swelling occurred in twenty four percent of treated patients and microhaemorrhages in twenty percent .
This is not a simple intervention. It is complex, intensive, and designed for people who already have measurable decline.
Which raises the more important question.
Why are we waiting until then?
At Cogmission Clinic We Work Earlier
In our cognitive clinic in Edinburgh, we rarely wait for dementia.
We see:
• Raised homocysteine
• Insulin resistance
• Low vitamin D
• Poor sleep architecture
• Chronic inflammation
• Hormonal transition in perimenopause
• Environmental toxin exposure
• Mitochondrial dysfunction
• Early vascular change
These are not theoretical risk markers. They are modifiable drivers of cognitive decline.
Alzheimer disease is not simply an amyloid problem. It is a metabolic, inflammatory, vascular and environmental condition that evolves silently for years.
By the time plaques are visible on a scan, the terrain has already shifted.
The Real Prevention Gap in Scotland
The decision not to fund donanemab was based largely on uncertainty about meaningful benefit and cost effectiveness .
Yet we are not routinely investing in:
• Early metabolic screening
• Personalised cardiovascular risk profiling
• Advanced lipid and homocysteine optimisation
• Hormone support during cognitive transition
• Sleep tracking and circadian repair
• Environmental toxin reduction
• Gut and immune modulation
• Vascular imaging such as CIMT scanning
We fund late stage intervention.
We do not fund early terrain correction.
That is the true gap.
Prevention Is Not Passive
Prevention is often misunderstood as general advice.
Eat better. Move more. Sleep well.
At Cogmission Clinic, prevention is precise.
It is testing.
It is measuring.
It is personalising.
It is intervening before structural damage occurs.
We use data to identify biological age shifts, inflammatory burden, methylation imbalance, insulin signalling disruption, and vascular changes years before cognitive decline becomes visible.
We do this because once neurons are lost, recovery becomes far more difficult.
A More Intelligent Strategy
Is amyloid relevant? Yes.
Is targeting plaques part of the future? Possibly.
But amyloid accumulation is one downstream feature of a much larger biological story.
If we continue to focus primarily on late stage pharmaceutical rescue, we will always be reacting rather than preventing.
Eighty percent of strokes are preventable. Vascular dementia and mixed Alzheimer pathology share the same metabolic drivers.
If we truly want to reduce dementia burden in Scotland, we must:
• Screen earlier
• Stratify risk sooner
• Support metabolic resilience
• Address inflammation
• Protect vascular integrity
• Optimise hormonal transitions
• Reduce toxic load
This is not radical. It is rational.
Our Position at our Cogmission Clinic
We are not anti innovation.
We are pro early intervention.
The rejection of donanemab does not mean there is no hope. It means we must widen our focus.
Waiting for a drug once decline is measurable is not a strategy.
Building resilience twenty years earlier is.
At our Cogmission Clinic in Edinburgh, that is where we place our attention.
Because cognitive health does not begin at diagnosis.
It begins in midlife.
And prevention, when done properly, is powerful.
