Second-line therapy for ulcerative colitis?

• A. Prednisone and Azathioprine
• B. Azathioprine and Infliximab
• C. Methotrexate and Adalimumab
• D. Mesalamine and Sulfasalazine

Answer: (B)

In ulcerative colitis, when first-line therapy (often 5-ASA agents) is not enough or patients become steroid-dependent, the approach shifts to more potent immunosuppressive and biologic strategies to induce and maintain remission. Azathioprine is an immunomodulator that suppresses T-cell proliferation and helps maintain remission, while infliximab is an anti-TNF agent that directly reduces intestinal inflammation driven by TNF-α. Using them together addresses both the need to sustain remission and the reduction of steroid dependence, and it also lowers the chance that the biologic will be neutralized by antibodies, improving durability of response. This combination is a common and effective second-line option for patients with steroid-refractory or steroid-dependent ulcerative colitis. By contrast, 5-ASA agents like mesalamine or sulfasalazine are typically reserved for milder disease, methotrexate is not routinely used in UC, and while anti-TNF therapy can be used, pairing it with azathioprine offers the best-supported strategy for achieving and maintaining remission in more active or refractory disease.