Which combination is commonly used as second-line therapy for ulcerative colitis when initial therapy fails?

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

Answer: (D)

When ulcerative colitis doesn’t respond to initial therapy, the goal is to induce remission and then maintain it with steroid-sparing strategies. A common second-line approach is to combine an immunomodulator with a biologic. Azathioprine helps keep the disease in remission and reduces the need for steroids, while infliximab, a TNF-alpha inhibitor, rapidly induces remission and promotes mucosal healing in moderate-to-severe disease. Using them together also lowers the risk that the infliximab will be neutralized by antibodies, improving long-term effectiveness.

The other options rely on either first-line agents or less routinely used combinations for this scenario, so they don’t fit the standard escalation approach as well as the azathioprine and infliximab pairing.