In a child with Crohn disease on prednisone who has active patchy colitis refractory to systemic steroids, what is the next step in management?

Management of Steroid-Refractory Pediatric Crohn's Disease with Colitis

The next step is to initiate monoclonal anti-TNF therapy (Option A), as steroid-refractory disease in a child with Crohn's colitis mandates escalation to biologic therapy according to ECCO/ESPGHAN guidelines. 1

Why Anti-TNF Is the Correct Choice

Steroid-refractory disease is defined as lack of clinical response to systemic steroids within 4 weeks, which triggers immediate escalation to anti-TNF therapy in pediatric Crohn's disease. 1 The ECCO/ESPGHAN consensus explicitly states that repeated steroid courses or steroid dependency should not be tolerated in children, and failure to respond mandates moving to biologics. 1

• Infliximab is FDA-approved for pediatric Crohn's disease and demonstrated 88% clinical response at Week 10 in the pivotal pediatric trial (Study Peds Crohn's), with 59% achieving clinical remission. 2
• The standard induction regimen is 5 mg/kg at weeks 0,2, and 6, followed by maintenance dosing every 8 weeks, which proved superior to every 12-week dosing (64% vs. 33% in clinical response at Week 54). 2
• Among patients on corticosteroids at baseline, 46% were able to discontinue steroids while maintaining remission at both Week 30 and Week 54 with every-8-week maintenance. 2

Why 5-ASA (Option B) Is Incorrect

5-ASA is not appropriate for steroid-refractory disease and would represent dangerous treatment delay. 1

• ECCO/ESPGHAN guidelines consider 5-ASA use in Crohn's disease "controversial and generally not recommended," especially when steroids have failed. 1
• 5-ASA may only serve as an adjunct in selected mild colonic disease—it is never indicated as rescue therapy after steroid failure. 1
• Using 5-ASA in this scenario would delay necessary biologic escalation, increasing risks of growth impairment, bone density loss, and metabolic complications from prolonged steroid exposure. 1

Why Ileal-Releasing Steroids (Option C) Are Incorrect

Budesonide (ileal-releasing steroid) is illogical after systemic steroid failure and is not indicated for colitis. 1

• ECCO/ESPGHAN recommends budesonide (9 mg daily) solely for mild-to-moderate isolated ileocecal disease as an alternative to systemic steroids—not as second-line therapy after prednisolone failure. 1
• Switching from more potent systemic prednisolone to less potent budesonide after steroid failure makes no pharmacologic sense and postpones required biologic treatment. 1
• This patient has patchy colitis, not isolated ileocecal disease, making budesonide anatomically inappropriate. 1

Pre-Treatment Assessment Before Anti-TNF Initiation

Before starting infliximab, verify the following: 1

• Immunization status, particularly varicella-zoster immunity
• Tuberculosis screening (blood test or PPD)
• Hepatitis B serology
• Rule out active infections

Consideration of Combination Therapy

Adding a thiopurine to anti-TNF therapy should be considered if the child has high-risk features: 1

• Perianal disease
• Severe growth retardation
• Deep ulcers on endoscopy
• Extensive disease involvement

The ECCO/ESPGHAN guidelines suggest combination therapy in thiopurine-naïve children with these characteristics when initiating anti-TNF. 1

Common Pitfalls to Avoid

Delaying escalation after steroid failure leads to short median time to relapse and exposes children to growth suppression, bone density loss, and metabolic complications from prolonged steroid use. 1

• Do not wait for "complete failure" or hospitalization—lack of response within 4 weeks is sufficient indication for anti-TNF therapy. 1
• Do not attempt multiple steroid courses—ECCO/ESPGHAN explicitly states this should not be tolerated in pediatric patients. 1
• Infliximab has demonstrated prolonged duration of response in children with early disease (50% maintained response through 12 months) compared to late disease (0% maintained response), emphasizing the importance of early escalation. 3

Safety Monitoring

While infliximab is generally well-tolerated in pediatric populations, careful attention should be paid to: 4

• Infections (most common adverse event)
• Infusion reactions
• Rare but serious risk of hepatosplenic T-cell lymphoma when combined with purine analogs (azathioprine/6-MP)