A 41 year old male patient presented with recurrent episodes of bloody diarrhea for 5 years. Despite regular treatment with adequate doses of sulfasalazine, he has had several exacerbations of his disease and required several weeks of steroids for the control of flares. What should be the next line of treatment for him?

Azathioprine and 6-mercaptopurine (6-MP) are purine analogues commonly employed in the management of glucocoicoid-dependent IBD. Azathioprine is rapidly absorbed and conveed to 6-MP, which is then metabolized to the active end product, thioinosinic acid, an inhibitor of purine ribonucleotide synthesis and cell proliferation. These agents also inhibit the immune response. Efficacy can be seen as early as 3-4 weeks but can take up to 4-6 months. Probiotics have shown to reduces disease activity in IBD Lactobacillus Bifidobacterium Taenia suis Saccharomyces boulardii