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Para quién está indicado y para quién no el primer fármaco aprobado en Europa contra el Alzheimer El nuevo fármaco deberá ser prescrito y su tratamiento controlado por neurólogos. Getty
A finales de 2024 la Agencia Europea del Medicamento aprobó el primer fármaco contra el Alzheimer tras décadas de investigación , el Lecanemab, que se comercializará con el nombre de Lequembi. La noticia fue acogida con gran alegría por los enfermos y familiares afectados por la enfermedad, por primera vez en la historia se lograba un fármaco que demostraba ser eficaz para luchar contra una enfermedad que parecía invulnerable . Pero tras la noticia viene el análisis, y la euforia se ha rebajado considerablemente, el fármaco solo es eficaz en etapas tempranas, tiene considerables efectos secundarios, y exige un seguimiento de cada paciente muy costoso para el Sistema Nacional de Salud.
Además, para su aprobación la EMA ha impuesto unas exigencias que limitan mucho el tipo de pacientes a los que se les podrá suministrar. ¿Quién podrá beneficiarse de este medicamento? ¿Cuándo estará disponible? ¿Puede suministrarse a cualquier enfermo de alzhéimer? ¿Cuáles son sus resultados? Despejemos incógnitas.
Situación en España Antes de que Lequembi se pueda usar en España debe pasar unos trámites de la Agencia Española del Medicamento. Durante 2025, esta agencia reguladora deberá decidir si se incluye entre los fármacos financiados públicamente por el Sistema Nacional de Salud. Es posible que se apruebe su comercialización en España, pero si no se incluye entre los medicamentos financiados públicamente, su elevado precio lo hará prácticamente inasumible para la gran mayoría de ciudadanos. El precio del tratamiento en Estados Unidos ronda los 26.000 dólares al año, solo por el medicamento . A esto habría que añadir el coste de los escáneres cerebrales periódicos que son necesarios para hacer un seguimiento de cada paciente.
Uso restringido Además, aunque fuera aprobado e incluido entre los medicamentos financiados públicamente, solo podrá administrarse a un número muy reducido de enfermos. Solo podrán recibir Lecanemab los pacientes con diagnóstico de alzhéimer en etapas iniciales. Para establecer el diagnóstico debería realizarse una punción lumbar, o una tomografía de emisión de positrones (PET) de amiloide, una prueba costosa y de difícil acceso. En España se desconoce el número de personas con Alzheimer en etapas tempranas, ya que su diagnóstico temprano es una de las carencias de nuestro sistema de salud.
Por otra parte, para recibir el tratamiento los enfermos deberán ser portadores de una (o ninguna) copia del gen ApoE 4, por lo que será necesario un examen genético previo. Cabe señalar que más del 95% de los mayores de 65 años que tienen dos copias del gen APOE4 desarrollan alzhéimer. Todas estas personas quedan excluidas del tratamiento.
Más restricciones El medicamento sólo podrá ser prescrito y administrado por especialistas en enfermedad de alzhéimer , lo que asegura que los pacientes recibirán un manejo adecuado durante todo el proceso, pero deberán ser sometidos a controles regulares mediante resonancias magnéticas para detectar posibles efectos secundarios. Esta monitorización constante forma parte de las medidas para garantizar la seguridad de los pacientes, pero supondría un enorme aumento de gasto en las cuentas de la sanidad pública.
Efectos secundarios Todas estas precauciones responden a los resultados de los ensayos clínicos, que han producido efectos secundarios como hemorragias en el 17% de los pacientes tratados y edemas cerebrales en el 13% .
El doctor David Pérez Martínez es el jefe de Servicio de Neurología del Hospital Doce de Octubre de Madrid, una de las unidades de Neurología más prestigiosas de nuestro país, y presidente de la Asociación Madrileña de Neurología. Pérez Martínez muestra su cautela a la hora de analizar la eficacia del Lecanemab: “es el primer ensayo clínico claramente eficaz desde hace más de 20 años en la enfermedad. Mejoró significativamente la puntuación en la escala habitual de ensayos clínicos en −0.45 puntos. Aunque el resultado es positivo, la relevancia clínica es dudosa , ya que la diferencia de −0.45 puntos es difícilmente apreciable por el paciente o familiares. Se ha estimado que una diferencia relevante estaría entre 1 y 1.5 puntos aproximadamente dependiendo del estadio de la enfermedad ”, explica el neurólogo.
“La clave es saber si la terapia se puede comportar como un modificador del curso de la enfermedad y no exclusivamente como un fármaco con efecto sintomático. En el primer caso la diferencia entre los pacientes tratados con los no tratados aumentaría paulatinamente con el tiempo. Sin embargo, este escenario no está demostrado y habría que esperar a los resultados de los estudios observacionales a cuatro o cinco años que están en marcha. Los resultados son modestos y no exentos de efectos adversos. Además, requerirían de una logística en los servicios asistenciales compleja y costosa. Dicho esto, abre una esperanza a nuevas terapias lo que es un aliciente para impulsar la investigación”, señala el experto.
Voces en contra Alberto Espay es director de la cátedra de Neurología en la Universidad de Cincinnati, y se ha posicionado en contra del uso del Lecanemab. “El Lecanemab no mejorará la salud de los enfermos, puede que empeore más lentamente, pero se enfrentan a una posibilidad de 1 a 4 de sufrir inflamación o hemorragia cerebral , y su cerebro se encogerá más rápido. Los riesgos son altos y los beneficios, minúsculos” ha explicado el profesor.
El experto es más contundente al afirmar que “Lecanemab tiene como objetivo eliminar el amiloide del cerebro. El amiloide es la respuesta normal del cerebro a diversos agentes a los que nos exponemos mientras envejecemos, pero no es la causa de la enfermedad de alzhéimer. La mayoría de las personas con amiloide en el cerebro no padecen alzhéimer. Eliminar el amiloide crea una ilusión de progreso, pero no aborda las causas subyacentes ni mejora la memoria. Este medicamento podría arruinar a las familias o sobrecargar las cuentas de la Sanidad, lo que sería aceptable si el tratamiento supusiera una diferencia. Este no vale la pena” , asegura Espay.
Voces a favor Por su parte, Pablo Martínez-Lage, neurólogo, director científico en Fundación CITA- Alzhéimer opina que “hay que felicitarse. Es un fármaco que consigue cambiar la historia natural de la enfermedad en sus fases más iniciales , en las que todavía no hay dependencia ni demencia. Cambia la progresión de la enfermedad en personas a las que se diagnostica alzhéimer cuando todavía están haciendo una vida normal o casi normal. Por tanto, contribuye a la promoción de la autonomía de las personas, que es de lo que va la Ley de Dependencia, que no es de dependencia, sino de promoción de la autonomía. Nuestros 17 sistemas sanitarios se tendrán que preparar para facilitar el diagnóstico temprano de las personas, y decidir si lo financian o no. Ahora entra en juego la creatividad público-privada para que la compañía y las administraciones acuerden precios que sean razonables de acuerdo con los cálculos que ya están más que hechos y publicados. Yo confío en la creatividad de nuestros políticos para que sepan acordar precios asequibles y que no solo se apruebe la comercialización en España, sino que el fármaco llegue a las casas de las personas y no sea un tratamiento solo para ricos” , concluye Martínez-Lage.
Qué dicen los afectados La Confederación Española de Alzhéimer y otras demencias (Ceafa) celebró la noticia. “Aunque la efectividad del 27% del fármaco pueda parecer modesta, lo cierto que, comparada con la que existe en la actualidad, es muy importante", subraya la ONG, que considera que, con su decisión, “la EMA ha evitado la discriminación a la que los europeos podían haberse visto abocados frente a otros países como Estados Unidos, Reino Unido, Japón, China, Arabia Saudí o Israel que ya disponen del tratamiento”, señala Ceafa, quien añade que “es un paso importante, pero queda todavía otro, el de que el Ministerio de Sanidad lo incluya en la cartera de servicios del Sistema Nacional de Salud”.
Ceafa ha criticado el abandono del Plan Nacional de Alzheimer que se elaboró en 2019 y que duerme en un cajón el sueño de los olvidados. La organización ha puesto en marcha el Pacto por el Recuerdo , al que se han adherido algunas las sociedades científicas de neurología más importantes del país, y que reclama avances en tres asuntos que consideran esenciales: un censo oficial de pacientes con Alzheimer; un diagnóstico precoz para detectar la enfermedad en estadíos tempranos; y una ruta de diagnóstico y tratamiento coordinada y eficiente , con la dotación de medios económicos, materiales y humanos necesarios que permita el acceso equitativo a los mejores tratamientos farmacológicos, no farmacológicos, y de cuidados.
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