A 32-year-old woman with Crohn's disease involving ileum and cecum (L1, A2 — Montreal classification) has failed mesalamine and now requires escalation. Colonoscopy shows deep linear ulcers with cobblestoning. CRP 45 mg/L, fecal calprotectin >1500 µg/g. She has no perianal disease. According to ECCO 2023 guidelines, the preferred induction agent for moderate-severe luminal Crohn's is:
- A High-dose oral prednisolone (40 mg/day) for induction
- B Ustekinumab (anti-IL-12/23) as preferred first biological
- C Anti-TNF therapy (infliximab or adalimumab) ± immunomodulator (azathioprine/methotrexate) ✓
- D Exclusive enteral nutrition for 8 weeks
Explanation
For moderate-to-severe Crohn's disease (activity indices, deep ulceration, elevated CRP/calprotectin), ECCO 2023 and ACG guidelines recommend anti-TNF therapy (infliximab or adalimumab) as the preferred biological, especially with combination immunomodulator therapy to reduce immunogenicity and improve remission rates. The SONIC trial demonstrated that infliximab + azathioprine combination was superior to either agent alone in achieving corticosteroid-free remission. Corticosteroids are used for acute induction but have no maintenance role and cause long-term side effects. Ustekinumab is preferred in patients failing anti-TNF or with inadequate response. Exclusive enteral nutrition is preferred in pediatric Crohn's.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.