Rutgeerts Infliximab Patients who had 36 weeks Fall in CDAI 70 points after 8 weeks CDAI 150 after 8 weeks et al7 10 mg/kg responded to a 62% infliximab 53% infliximab (n= 73) 8 weekly single dose of 37% placebo 20% placebo (4 doses) 5 mg/kg in maintenance of remission and long-term safety is greater for azathioprine12, 14 than for other immunosuppressants, the former remains the drug of choice for patients with frequently recurring or chronic active disease. In the 10% of patients who are intolerant of or unresponsive to azathioprine, the therapeutic options are methotrexate, cyclosporine, and mycophenolate mofetil. Anti-TNF-is a potential option, but trials are needed to compare it with the other options and with the newer immunosuppressants, such as tacrolimus and thalidomide. Anti-TNF-also has a role for the ill patient in whom an effective treatment is urgently required while immunosuppression with azathioprine, which can take up to 6 months, is being established. Infliximab is licensed for a single infusion for severe active disease. One infusion of 5 mg/kg costs about UK£ 1920 for a 70 kg patient. Generally, if remission is induced it will need to be maintained with further drug therapy, such as azathioprine. Use of infliximab to maintain remission would cost over£ 12 000 per year. Whether patients are best treated by regular infusions or only as the condition demands remains to be established.

For patients with symptom-producing fistulating disease, anti-TNF-could be considered after 6 months of treatment with azathioprine or 6-mercaptopurine. Early use of the antibody as primary therapy in patients with extensive severe perianal disease, while the effect of azathioprine is being established, may be useful, although there are no trial data for this effect. Abscesses should be drained. The presence of one or more surgically inserted sutures (setons) to maintain drainage may facilitate healing without infection. There is no evidence on use of the antibody for maintenance therapy in fistulous disease. In addition, there were too few patients for assessment of the value of this treatment for abdominal fistulae.