Could another biologic work better for my Crohn’s?

Question

Hello doctor,

I am 35 and have been dealing with Crohn’s disease since college, but it has been really hard to manage since I had my daughter two years ago. I was in remission during pregnancy on Sulfasalazine, but everything became chaotic after delivery. I had to have emergency surgery eight months ago to remove 18 inches of small bowel because of a stricture and perforation.

I am now on Infliximab every eight weeks, but I am still having abdominal pain and diarrhea four to five times a day. My CRP stays around 35, and my fecal Calprotectin is 850 even while on the biologic. The surgeon said I might need another operation if the inflammation does not improve.

Breastfeeding was impossible because of the medications and flare-ups, which made me feel terrible as a new mom. I am also dealing with perianal fistulas that constantly drain and make sitting uncomfortable. My husband wants another baby, but I am scared the Crohn’s disease will get worse again after pregnancy. Can I switch to a different biologic that works better?

Please help.

Thank you.

Answer 1

Hello,

Welcome to icliniq.com.

I understand your concern.

I can hear how overwhelming this has been for you, especially managing Crohn’s disease on top of surgery, medications, and the challenges of motherhood. From what you describe, it seems your current treatment with Infliximab is not giving you full control of the disease, since your CRP (C-reactive protein) and fecal calprotectin remain high, and you are still symptomatic with diarrhea, abdominal pain, and ongoing perianal fistula drainage.

In such situations, switching to another biologic or a small-molecule therapy is a very reasonable consideration. Options include Adalimumab (another anti-TNF (tumor necrosis factor) agent), Ustekinumab (targets IL-12/23), Vedolizumab (a gut-selective integrin blocker), or even Upadacitinib (an oral JAK inhibitor, though its use may be more limited in women planning pregnancy). Each has different effectiveness profiles for Crohn’s disease, and some, like Ustekinumab and Vedolizumab, are often chosen if patients do not respond adequately to Infliximab.

Since you also have perianal fistulizing disease, anti-TNFs are usually first-line, but if one TNF inhibitor fails, sometimes switching to another can still work, or your gastroenterologist may recommend moving to Ustekinumab. Regarding pregnancy, it is true that flares can sometimes worsen after delivery, but many women with Crohn’s have healthy pregnancies when the disease is well controlled. Most of the biologics I mentioned are considered safe in pregnancy, especially compared to the risks of uncontrolled inflammation.

The decision should be individualized, taking into account your past response, side-effect tolerance, and your plans for having another child. I would strongly encourage you to discuss with your gastroenterologist whether therapeutic drug monitoring of Infliximab levels has been done, since sometimes increasing the dose or shortening the infusion interval can restore effectiveness before switching medications. At the same time, it is important to address your perianal fistulas, which may require combined medical and surgical management.

You are carrying a lot physically and emotionally, and it is understandable to feel fearful about another pregnancy, but getting your Crohn’s under tighter control first will give you the best chance of stability if you choose to expand your family.

I hope this helps.

Kindly follow up if you have more concerns.

Thank you.