TNF and Cowden disease: Previous studies showed no benefit of thiopurines initiated very soon after CD diagnosis (with consistent data in our study),11 12 and there is clear evidence from trials such as SONIC for improved efficacy when thiopurines are combined with infliximab for the treatment of CD.50 Given recent substantial reductions in the cost of biosimilar anti-TNF therapy, and the evidence presented regarding the relative lack of durable effectiveness of thiopurine monotherapy in CD, there is perhaps a need to re-evaluate treatment strategies.