Abstract: Introduction: Sequencing therapy in CD is currently intensively discussed due to the development of novel drugs and lack of standardized criteria for drug positioning in first and further treatment lines. The aim of this study was to compare the efficacy of a second line advanced therapy in Romanian patients with CD who have failed an anti-TNF agent. Methods: We performed a multicenter retrospective study that included adult patients with CD who had secondary loss of response after an initial response with an an-ti-TNF drug. The main outcome was clinical remission at 12 weeks of second-line treatment (CDAI < 150). Secondary outcomes included clinical response (decrease of CDAI ≥ 25%), persistence of therapy at 1 year and rates of adverse events. Results: From 2008 to 2024, 216 patients were either switched to another anti-TNF or swapped to another therapeutic class due to failure of a first anti-TNF drug. Secondary lines of treatment in-cluded infliximab (IFX), adalimumab (ADA), vedolizumab (VDZ), ustekinumab (UST). The highest rate of clinical remission (81%) was obtained with the sequence ADA-IFX in 26/32(81%) patients and ADA-UST in 62/82(76%) patients, followed by IFX-UST in 22/33(67%) and IFX-ADA 34/51(67%). Persistence on therapy at 1 year was better for the sequence ADA-UST(73%) and IFX-UST(67%) and ADA-IFX(63%) compared to IFX-ADA(59%) and IFX-VDZ(44%)(p< 0.001). Conclusions: In patients with CD who have failed a first anti-TNF, the highest rate of clinical re-mission at 12 weeks was obtained with second line IFX and UST whilst vedolizumab showed lower efficacy. UST demonstrated the most favorable long-term treatment persistence at 1 year.