Infliximab vs adalimumab in esophageal CD

What is known

• In one case, esophageal lesions deteriorated despite infliximab after prior adalimumab, and healed only after switching to upadacitinib for anti-TNF-refractory disease. ¹
• A patient lost response to infliximab with high anti-infliximab antibodies and undetectable drug levels, then was managed with adalimumab plus dapsone. ²
• ECCO guidance favors a lower threshold for starting TNF-α inhibitors in esophageal involvement given its poor prognosis; infliximab, adalimumab, and ustekinumab have all been associated with endoscopic improvement. ³
• Esophageal CD is characterized as an aggressive phenotype for which combination topical plus systemic therapy is advised, and both anti-TNF agents also appear in refractory cases rescued by JAK inhibitors. ^3,4

What is unknown / caveats

• Evidence limited to single-patient case reports; no comparative or controlled data
• Several reports document anti-TNF failure/loss of response rather than efficacy
• No ulcer-healing outcome directly contrasts infliximab vs adalimumab
• The corpus contains no head-to-head data, so neither anti-TNF can be ranked over the other for esophageal ulcer healing.

References

1. Nakamura N, Honzawa Y, Ito Y, Sano Y, Yagi N, Saito E, Fukata N, Naganuma M. Antitumor Necrosis Factor-Refractory Esophageal Lesions in Crohn's Disease Successfully Treated With Upadacitinib. ACG Case Rep J. 2025. PMID: 40386539.

2. Sánchez AR, Rogers RS, Sheridan PJ. Oral ulcerations are associated with the loss of response to infliximab in Crohn's disease. J Oral Pathol Med. 2005. PMID: 15610407.

3. Nathoo S, Hood WA, Keihanian S, Collinsworth AL, Glover SC. Tofacitinib for the treatment of tumor necrosis factor-α inhibitor refractory esophageal Crohn's disease: a case report. J Med Case Rep. 2016. PMID: 27663846.

4. Levy AN, Ali N, Andrici J, Hamilton MJ. It's What's Up Front That Counts-Part Two: Esophageal Crohn's Disease Complicated by Recurrent Upper Gastrointestinal Bleeding. Dig Dis Sci. 2019;64(12):3446-3450. PMID: 31677072.

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Draft, generated by the IBDology RAG and not yet clinician-reviewed. Answers are grounded in the retrieved literature listed above; a high faithfulness score means the answer matches its sources, not that the sources are correct.