A 28-year-old man with Crohn's disease involving the terminal ileum and right colon has had 3 relapses requiring corticosteroids in 18 months despite azathioprine 2.5 mg/kg/day. The TPMT activity is normal. Which is the MOST appropriate step per ECCO 2023 guidelines?
- A Add anti-TNF therapy (infliximab or adalimumab) to azathioprine (combination therapy) ✓
- B Increase azathioprine dose to 3 mg/kg/day
- C Switch to methotrexate monotherapy
- D Perform ileocolonic resection
Explanation
This patient has steroid-dependent Crohn's disease despite adequate azathioprine (confirmed by normal TPMT activity). ECCO 2023 guidelines recommend escalation to biologic therapy. Anti-TNF agents (infliximab, adalimumab) combined with azathioprine (combination immunomodulator + biologic) achieve higher rates of mucosal healing than either agent alone (SONIC trial: combination therapy significantly superior to monotherapy). The combination reduces immunogenicity (anti-drug antibody formation) to infliximab. Vedolizumab or ustekinumab are alternatives for patients with anti-TNF failure or contraindications.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.