needed to treat = 6). Efficacy of 5-ASAs in inducing remission was similar whether remission was defined clinically or endoscopically. Another meta-analysis of 38 studies in patients with mildly to moderately active proctitis or left-sided UC found that rectal 5-ASA was superior to placebo, with a pooled odds ratio (OR) of 8.30 (95% CI, 4.28–16.12; P < 0.00001) for symptomatic remission and 5.31 for endoscopic remission (95% CI, 3.15–8.92; P < 0.00001). There were no significant differences due to dose (1 or 4 g/d) or formulation (liquid, gel, foam, or suppository) (95). Rectal 5-ASA was also found to be superior to rectal corticosteroids for inducing symptomatic remission (OR, 1.65; 95% CI, 1.1–2.5) (95). Despite the superiority of rectal 5-ASA over rectal steroids, steroids remain an important option for patients with mildly active left-sided UC who cannot retain rectal 5-ASA, have hypersensitivity to 5-ASA, or who are not responding to 5-ASA (95). In left-sided UC, a meta-analysis of 4 RCTs using combination treatment with rectal 5-ASA enemas (1 g/d) combined with oral 5-aminosalicylate (at least 2 g/d) was more effective than oral 5-ASA alone for induction of remission (relative risk induction failure RR, 0.65; 95% CI, 0.47–0.91) (96). Another meta-analysis comparing the 2 regimens showed an RR of 0.86 for induction failure when using the combination therapy (95% CI, 0.81–0.91) (97). However, in patients with mildly active extensive colitis, oral 5-ASA at a dose of at least 2 g/d is preferred to induce remission (97,98). In a recent meta-analysis, a low dose of 2–2.4 g of 5-ASA was found to be just as effective as a higher dose (4.8 g/d) (RR, 0.91; 95% CI, 0.85–0.98) (97). A subgroup analysis indicated that patients with more active (moderate) disease may benefit from the higher dose of 4.8 g/d (99). Once-daily dosing of oral 5-ASA was demonstrated to be as effective as multiple doses daily and may facilitate compliance (99). In patients with mildly active UC who fail to reach remission with appropriately dosed 5-ASA, switching to an alternate 5-ASA formulation is not recommended because meta-analyses have not demonstrated a therapeutic difference between different formulations (100,101). However, no formal switch studies have been published. In patients with UC who fail to respond to oral 5-ASA therapy, oral corticosteroids can be used to induce remission. A meta-analysis showed that corticosteroids are more effective than placebo in induction of remission (RR, 0.65; 95% CI, 0.45–0.93) (102). The typical starting doses of oral prednisone are 40–60 mg/d, usually in a single dose, and clinical response is expected within 5–7 days of treatment. There were no observed differences, however, when starting at doses higher than 60 mg/d (103). The duration of systemic corticosteroids should be as short as possible with early initiation of steroid-sparing therapy. The speed of the taper should be guided by clinical symptoms, cumulative steroid exposure, and onset of action of alternate therapies. Budesonide is a locally acting corticosteroid with high first-pass metabolism and minimal systemic side effects. In patients with UC who fail to respond to 5-ASA, budesonide MMX 9 mg for 8 weeks was found to be superior in achieving a combined end point of clinical and endoscopic remission compared with continuing 5-ASA and placebo (P = 0.049) (104). The use of corticosteroid preparations with high first-pass metabolism and low systemic effects may be