A 48-year-old man with a history of Crohn's disease (ileocolonic, non-stricturing, non-penetrating) undergoes ileocolonoscopy showing severe mucosal inflammation with deep ulcers. His Harvey-Bradshaw Index is 12. He has had one course of prednisolone and is currently steroid-free. According to ECCO guidelines, the treatment strategy that best achieves deep remission (both clinical and endoscopic) is:
- A Azathioprine monotherapy
- B Combination infliximab + azathioprine (combination immunosuppression) ✓
- C Prednisolone maintenance
- D Mesalazine 4 g/day
Explanation
The SONIC trial demonstrated that combination therapy with infliximab + azathioprine achieves significantly higher rates of steroid-free clinical remission and mucosal healing compared to either agent alone in moderate-to-severe Crohn's disease. Azathioprine monotherapy is insufficient for severe endoscopic disease. Steroids are not appropriate for maintenance therapy. Mesalazine is ineffective for small bowel and ileocolonic Crohn's disease. The combination also reduces immunogenicity to infliximab through azathioprine-mediated reduction in anti-drug antibody formation.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.