Basic Science and Pathogenesis

Amyloid-related Imaging Abnormalities(ARIA) are adverse effects that occur during amyloid beta monoclonal antibody treatment for Alzheimer's disease, including edema-type ARIA and hemorrhage-type ARIA(ARIA-H). Few retrospective analysis have compared ARIA-H incidence among individual monoclonal antibodies, and a comprehensive comparison is currently lacking. After the approval of these antibodies, research has mainly focused on dosing frequency and drug dosage, leaving it unclear whether ARIA-H is associated with the specific characteristics of different monoclonal antibodies.

For monoclonal antibodies targeting Aβ clearance, we selected seven: Aducanumab, Bapineuzumab, Crenezumab, Donanemab, Gantenerumab, Lecanemab, and Solanezumab. Our data is derived from systematic reviews and meta-analyses of Phase III clinical trials. Data from Jeremic D et al.(Ageing Res Rev. 2023 Sep) and Qiao Y et al.(CNS Drugs. 2024 Mar). For the evaluation variables, we selected the following factors: the form of monoclonal antibody binding to Aβ protein, binding affinity, binding epitope, Fc subtype of the monoclonal antibody, and the Aβ clearance rate. ARIA-H occurrence was used as a categorical variable for differential analysis. We standardized all the data and compared the ARIA-H occurrence rates for seven mAbs, taking into account other dimensional variables to ensure they were as comparable or similar as possible.

The risk of ARIA-H, from highest to lowest, is as follows: Donanemab, Aducanumab, Bapineuzumab, Lecanemab, Gantenerumab, Crenezumab, Solanezumab. Besides, ARIA-H is associated with the characteristics of mAb. (1) More mature Aβ clearance is associated with a higher risk of ARIA-H.(2) Lower clearance of Aβ oligomers is associated with a higher risk of ARIA-H.(3) Aβ clearance closer to the N-terminus is associated with a higher risk of ARIA-H.(4) Monoclonal antibodies with an IgG4 structure are more likely to cause ARIA-H than those with an IgG1 structure.(5) Faster achievement of Aβ clearance thresholds is associated with a higher risk of ARIA-H.

This research enhances our understanding of ARIA-H and may guide future monoclonal antibody drug development, which may improve the cognition and overall prognosis of Alzheimer's disease patients.