A 28-year-old woman with Crohn's disease (ileocolonic, moderate-severe) fails mesalazine and azathioprine over 18 months. She has perianal fistulae. What is the MOST appropriate next-line biologic therapy?
- A Infliximab (anti-TNF) ✓
- B Vedolizumab (anti-integrin)
- C Ustekinumab (anti-IL12/23)
- D Tofacitinib (JAK inhibitor)
Explanation
Infliximab (anti-TNF monoclonal antibody) is the preferred first-line biologic for moderate-severe Crohn's disease, particularly in patients with perianal fistulizing disease—its fistula closure efficacy is established in ACCENT II trial (54% fistula closure vs. 19% placebo). It is often given with azathioprine to minimize immunogenicity (SONIC trial: combination superior to monotherapy). Vedolizumab (gut-selective anti-α4β7 integrin) and ustekinumab are effective but used after anti-TNF failure or when anti-TNF is contraindicated. 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.