A 38-year-old man presents with a 6-month history of episodic crampy lower abdominal pain, diarrhea, and a 5 kg weight loss. Colonoscopy shows skip lesions, cobblestone mucosa, and a fistulous tract between the terminal ileum and sigmoid colon. Biopsy reveals transmural granulomatous inflammation. He is started on corticosteroids. For long-term disease control and fistula healing, which is the MOST appropriate maintenance therapy?
- A 5-aminosalicylate (mesalazine) maintenance
- B Intermittent short courses of oral prednisolone
- C Rifaximin long-term antibiotic prophylaxis
- D Anti-TNF therapy (infliximab or adalimumab) ✓
Explanation
Crohn's disease with fistulizing complications is a high-risk feature that warrants biologic therapy. Anti-TNF agents (infliximab IV, adalimumab SC) are the only agents with proven efficacy for both luminal remission induction/maintenance and fistula closure in Crohn's disease. Mesalazine has minimal efficacy in Crohn's disease (unlike ulcerative colitis) and no role in fistulizing disease. Corticosteroids cannot be used for long-term maintenance as they do not prevent relapse, cause significant side effects, and have no fistula-healing properties. Rifaximin may have modest symptomatic benefits in luminal disease but is not standard maintenance for fistulizing Crohn's.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.