A 32-year-old man with Crohn's disease (ileal, inflammatory/non-stricturing) fails azathioprine therapy after 6 months (persistent flares). He is anti-TNF naïve. TPMT genotyping was normal. What is the most appropriate next-line biologic therapy according to ECCO 2023 guidelines?
- A Vedolizumab (anti-α4β7 integrin)
- B Infliximab + azathioprine combination (SONIC trial approach) ✓
- C Ustekinumab (anti-IL-12/23)
- D Tofacitinib (JAK inhibitor)
Explanation
The SONIC trial established that combination therapy with infliximab + azathioprine is superior to either agent alone for inducing and maintaining mucosal healing in Crohn's disease (38% clinical remission with infliximab alone vs. 56% with combination). For anti-TNF naïve patients with moderate-severe luminal Crohn's, infliximab (or adalimumab) is the preferred first biologic; combination with an immunomodulator reduces immunogenicity and enhances durability. Ustekinumab and vedolizumab are alternatives if anti-TNF contraindicated or after failure. Tofacitinib is approved for UC, not Crohn's disease.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.