A 30-year-old woman with Crohn's disease involving the terminal ileum has been on azathioprine for 2 years. She now presents with worsening abdominal pain, weight loss, and a CRP of 68 mg/L. Colonoscopy shows deep ulcers and stricturing in the terminal ileum. What is the most appropriate next step in management?
- A Increase azathioprine dose to maximum
- B Add anti-TNF therapy (infliximab or adalimumab) — 'top-down' escalation ✓
- C Switch to mesalazine
- D Immediate surgical resection
Explanation
This patient has active moderate-to-severe Crohn's disease with objective evidence of inflammation (elevated CRP, endoscopic ulcers and stricturing) despite thiopurine therapy. Anti-TNF therapy (infliximab or adalimumab) is indicated for steroid-dependent, steroid-refractory, or immunomodulator-refractory Crohn's disease. Current guidelines support early introduction of biologics in patients with poor prognostic features (stricturing/penetrating disease, perianal involvement, elevated CRP). Mesalazine is not effective for Crohn's disease. Surgery is reserved for complications (obstruction, fistula, abscess) not responsive to medical therapy.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.