Clinical heterogeneity, incomplete reporting of follow-up data, and different disease-defined endpoints across numerous clinical studies limit the assignability to individual patients. anti-TNF antibodies. New small molecules (Janus kinase inhibitors) are encouraging with an acceptable safety profile and efficacy in UC. Further, strategies that target the intestinal microbiome are currently considered for patients with active or relapsing UC, and may in the future open up new therapeutic options. and cytomegalovirus contamination should be requested in view Indaconitin of the rising incidence and association of these infections with increased mortality in patients with UC. If active colitis is considered as the main cause of symptoms, therapy should be induced promptly. There is a plethora of different clinical scoring Indaconitin systems used in clinical trials; however, for daily practice it is most important to differentiate between patients with moderate or moderate activity Indaconitin and those with severe UC. Patients with severe disease should be hospitalized. Hospitalization should be considered for all patients who have more than 6-10 bloody stools per day, associated with fever, tachycardia, or an increase in erythrocyte sedimentation Indaconitin rate (ESR) according to the criteria of Truelove and Witts [11]. Mild to Moderate Activity in Proctitis If moderate to moderate inflammation is limited to the rectum, topical treatment with mesalamine is the first-line therapy. Marshall et al. [12] confirmed the superiority of this treatment in inducing remission. The preferred treatment is usually 1-g mesalamine suppositories once daily, since Andus et al. [13] exhibited non-inferiority of this approach to divided doses. Additionally, there is no dose response above 1 g mesalamine per day. Topical steroids can be used as second-line therapy since topical mesalamine is superior to rectal corticosteroids Indaconitin [14], or as an alternative for patients with intolerance to topical mesalamine [15]. Safdi et al. [16] postulated that combined topical and oral mesalamine treatment seems to be more effective; however, this study included patients with left-sided colitis also. Currently, there is a lack of studies for only proctitis treated with a combination of oral and topical mesalamine. A combination of topical mesalamine and topical steroid appears to be more effective than either agent alone [17]. Patients who fail to respond to the regimens above require additional treatment with oral prednisolone. Left-Sided Colitis The recommended treatment for moderate to moderate distal/left-sided UC is usually a combination of topical mesalamine enemas/foams 1 g/day and oral mesalamine 2 g/day [7,15]. Combined therapy showed significantly higher efficacy in disease improvement and led to faster improvement of rectal bleeding [16,18]. Furthermore, topical mesalamine in comparison to oral mesalamine alone showed a higher rate of mucosal absorption [19], which supports the concept of combined therapy since the therapeutic effect of mesalamine correlates with its mucosal concentration [20]. Topical therapy foam enemas and liquid enemas are seen as equivalent treatment options for inducing remission [21]; using low volume enemas might result in better patient compliance [22]. An equivalent alternative to MSK1 rectal mesalamine may be rectal beclomethasone dipropionate [23]. Much like topical rectal medication, single oral doses of mesalamine are non-inferior to divided doses per day [24] and should improve patient adherence [25]. Different from that is the dose response to oral mesalamine: concerning induction of remission, Ford et al. [26] showed in their meta-analysis evidence that doses of 2 g/day are more effective than doses of 2 g/day. The ASCEND trial even showed a benefit of double doses with 4. 8 g/day at week 6 concerning mucosal healing and induction of remission, although there was no further benefit at week 8 [27]. Hence, the European guideline recommends at least 2 g mesalamine per day [7]. The use of systemic steroids needs to be resolved at the latest 14 days after treatment failure. Extensive Colitis The basic therapy recommendation for extensive moderate to moderate UC is similar to that for distal or left-sided colitis [15]. A combined therapy using oral and topical 5-ASA medication is usually superior to single use of either. Also, there is no significant difference in the induction of remission concerning numerous 5-ASA formulations, although mesalamine is better tolerated [28,29]. This is different for patients with limited distribution of UC where use of systemic corticosteroids should be considered earlier for those with.