LITERATURE UPDATE
Alzheimer’s disease: the importance of blood-based biomarkers
With the introduction of potential new treatments for patients with Alzheimer’s disease, early diagnosis is vital, and this is where detection of appropriate biomarkers is crucial. Here, Pathology in Practice Science Editor Brian Nation looks at recent published work in this area, all of which are free to access.
Alzheimer’s Association Clinical Practice Guideline on the use of blood-based biomarkers in the diagnostic workup of suspected Alzheimer’s disease within specialized care setings Palmqvist S, Whitson HE, Allen LA et al. Alzheimers Dement. 2025 Jul; 21 (7): e70535. doi: 10.1002/alz.70535.
A panel of clinicians, subject-mater experts, and guideline methodologists convened by the Alzheimer’s Association conducted a systematic review and formulated evidence-based recommendations for using blood-based biomarkers (BBMs) in the diagnostic workup of suspected Alzheimer’s disease (AD) within specialised care setings. The scope focuses on individuals with objective cognitive impairment, including those with mild cognitive impairment (MCI) or dementia, who are undergoing evaluation by providers trained and experienced in memory disorders, where AD is the suspected underlying aetiology. The panel conducted a systematic
review to assess the diagnostic accuracy of BBMs in detecting AD pathology. The BBMs of interest included plasma phosphorylated-tau (p-tau) and amyloid- beta (Aβ) tests measuring the following analytes: p-tau217, ratio of p-tau217 to non-p-tau217 ×100 (%p-tau17), p-tau181, p-tau231, and ratio of Aβ42 to Aβ40. The reference standard tests included cerebrospinal fluid (CSF) AD biomarkers, amyloid positron emission tomography (PET), or neuropathology. The panel applied the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of the evidence and the GRADE evidence-to- decision (EtD) Framework to develop its recommendations. The key recommendations in this Clinical Practice Guideline (CPG) are:
1) BBM tests with ≥90% sensitivity and ≥75% specificity can be used as a triaging test and 2) BBM tests with ≥90% sensitivity and specificity can serve as a substitute for amyloid PET imaging or CSF AD biomarker testing in patients with cognitive impairment presenting to specialised care for memory disorders. The panel cautions users of this guideline that there is significant variability in diagnostic test accuracy and many commercially available BBM tests do not meet these thresholds, especially using a single cut- off. Additionally, these tests do not serve as a substitute for comprehensive clinical evaluation by a healthcare professional and should be used only as part of a full diagnostic workup of patients with cognitive impairment presenting to
specialised care setings, and with careful consideration of pre-test probability of AD pathology.
This CPG provides performance-based,
brand-agnostic recommendations for the use of BBMs in the diagnostic workup of suspected AD within specialised care setings. By linking recommendations to a systematic review and associated living updates, and using a robust and transparent methodology, the guideline ensures scientific rigor, adaptability, and sustained relevance as evidence evolves. Clinicians are encouraged to stay informed about emerging paradigms such as biomarker combinations or ratios and multi-threshold testing that may further refine the diagnostic accuracy of BBMs as the field evolves.
Senile plaques seen in the cerebral cortex in a patient with presenile onset of Alzheimer’s disease (Silver impregnation).
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