Perianal Crohn's Biologic Choice — RACP Adult Medicine MCQ

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HardGastroenterology & HepatologyPerianal Crohn's Biologic ChoiceRACP Adult Medicine

A 42-year-old woman with Crohn's disease on vedolizumab develops a new perianal fistula. Despite vedolizumab, the fistula is not healing. What biologic switch should be considered for perianal fistulising Crohn's?

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Correct answer: C — Tofacitinib

Anti-TNF therapy (infliximab has the strongest evidence – ACCENT II trial) is the treatment of choice for perianal fistulising Crohn's disease. Vedolizumab (gut-selective anti-integrin) has limited efficacy for perianal disease due to its selective gut homing mechanism. Switching to infliximab (or adalimumab) combined with surgical management (seton, EUA with drainage) is the recommended approach. Ustekinumab has emerging but more limited data for fistulising CD.

Reference: eTG – 2025 – Gastrointestinal; ECCO – 2024 – Perianal Crohn's Disease Guidelines