aflibercept + brolucizumab

A combination therapy approach for neovascular age-related macular degeneration (nAMD), particularly in cases where patients show inadequate response to monotherapy with either agent. This combination involves alternating monthly injections of both anti-VEGF agents to manage persistent macular fluid. ## Mechanism and Clinical Use This combination therapy leverages the complementary mechanisms of both drugs to improve outcomes in difficult-to-treat cases. In clinical practice, the combination is typically administered by alternating between brolucizumab (6 mg/0.05 mL) and aflibercept (2 mg/0.05 mL) on a monthly schedule[1]. This approach has shown promising results in patients who experience persistent macular fluid despite treatment with either agent alone. Studies have demonstrated that this combination therapy can be particularly effective for patients who show increased macular fluid when brolucizumab monotherapy is extended to an 8-week interval[1]. In these cases, alternating between the two agents on a monthly basis has been associated with improved macular fluid on optical coherence tomography (OCT) in approximately 80% of patients, with 70% maintaining stable or improved best-corrected visual acuity (BCVA)[1]. ## Clinical Evidence In real-world studies, the combination therapy has been well-tolerated and can be considered for eyes with persistent macular fluid despite treatment with other anti-VEGF therapies[1]. One study showed that after switching to this combination approach, 80% of patients had improved macular fluid on OCT after a median follow-up of 53 weeks[1]. The efficacy of this combination may be attributed to the different molecular structures and pharmacokinetic profiles of the two agents. Brolucizumab is a humanized single-chain antibody fragment inhibitor of VEGF-A, while aflibercept is a recombinant fusion protein[3]. Their complementary mechanisms may provide more comprehensive VEGF inhibition than either agent alone. ## Administration and Coding For billing purposes, aflibercept should be reported with HCPCS code J0178, while brolucizumab-dbll should be reported with HCPCS code J0179[6][7]. The administration must be billed on the same claim as the drug when used in combination therapy.