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Anti-TNF for Crohn Fistulae — RACP Adult Medicine MCQ

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ModerateGastroenterologyAnti-TNF for Crohn FistulaeRACP Adult Medicine

A 30-year-old woman with Crohn disease on azathioprine develops a steroid-dependent flare (requires prednisolone >10 mg to maintain remission). She has perianal fistulising disease. CRP is elevated. What is the most appropriate treatment escalation?

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Correct answer: E — Anti-TNF (adalimumab or infliximab)

Steroid-dependent Crohn disease with perianal fistulae failing immunomodulator therapy requires biologic escalation. Anti-TNF (infliximab preferred for perianal disease — ACCENT II trial, or adalimumab) is first-line biologic for moderate-severe Crohn. Combination therapy (anti-TNF + immunomodulator) is superior to monotherapy for induction and maintenance (SONIC trial: infliximab + azathioprine > either alone). Perianal fistulae also require surgical assessment (EUA, seton placement).

Reference: GESA – 2024 – Crohn; ECCO 2024; SONIC Trial