A 28-year-old woman with Crohn's disease has ileocolonic involvement (L3, B1, inflammatory) with moderate activity (HBI 9). She failed mesalamine and is on azathioprine for 6 months without remission. What is the most appropriate next step per ECCO guidelines?

• A Start anti-TNF therapy (infliximab or adalimumab) — escalate to biologic therapy ✓
• B Add methotrexate to azathioprine
• C Increase azathioprine dose to 3 mg/kg/day
• D Start exclusive enteral nutrition for 12 weeks

Explanation

In Crohn's disease with moderate-to-severe activity failing conventional immunomodulators (thiopurines) after adequate trial (3-6 months), escalation to biologic therapy is recommended per ECCO 2023 guidelines. Anti-TNF agents (infliximab, adalimumab) or combination therapy (anti-TNF + immunomodulator) are preferred for early biologics. Combining two immunomodulators (azathioprine + methotrexate) is not recommended and increases toxicity. Enteral nutrition is an adjunct in pediatric CD. Increasing azathioprine beyond 2-2.5 mg/kg is generally not beneficial and increases toxicity.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.