difficult, and this is not currently a recommended treatment option for UC (115). 16. In patients with mildly active ulcerative proctitis, we recommend rectal 5-ASA at a dose of 1 g/d for maintenance of remission (strong recommendation, moderate quality of evidence). 17. In patients with mildly active left-sided or extensive UC, we recommend oral 5-ASA therapy (at least 2 g/d) for maintenance of remission (strong recommendation, moderate quality of evidence). 18. We recommend against systemic corticosteroids for maintenance of remission in patients with UC (strong recommendation, moderate quality of evidence). Summary of evidence A meta-analysis of 11 trials demonstrated the efficacy of oral 5-ASA agents (mesalamine, olsalazine, and sulfasalazine) compared with placebo in patients with quiescent UC (distal, left-sided, or extensive colitis) in maintenance of remission (94). The overall RR of relapse was 0.65 (95% CI, 0.55–0.76). Fewer patients on the high-to-standard dose of 5-ASA (≥2 g/d) experienced relapse of their quiescent disease compared with those on low dose (<2 g/d) (RR of relapse, 0.79; 95% CI, 0.64–0.97). The type of 5-ASA agent was not found to predict rates of relapse in these patients with controlled UC. In a recent Cochrane meta-analysis, oral 5-ASA compared with sulfasalazine was associated with a higher rate of failure to maintain clinical or endoscopic remission (RR, 1.14; 95% CI, 1.03–1.27) and a higher rate of failure to maintain remission in general (RR, 1.08; 95% CI, 0.92–1.26). (101) However, sulfasalazine is often limited by intolerance (headache and nausea), allergy to the sulfa moiety, and need for multiple daily doses. A meta-analysis of 7 trials assessed the efficacy of topical 5-ASA in preventing relapse in controlled UC (116). Only 1 of the included placebo-controlled trials assessed patients with extensive UC, whereas the remaining trials recruited patients with proctitis, proctosigmoiditis, or left-sided colitis. Among the trials that reported disease duration, the mean duration was 5–7 years. Compared with patients receiving placebo, patients receiving topical 5-ASA had an RR of 0.60 (95% CI, 0.49–0.73) for relapse. Two trials evaluated time to relapse in patients with rectal disease, and both found that patients receiving topical 5-ASA experienced relapse at a later time compared with those receiving placebo. Corticosteroids are ineffective in maintaining remission and are limited by their side effects and possible complications. Therefore, corticosteroids are not used for maintenance of remission (117–120). 22. Strategies for the management of the nonhospitalized patient with moderately to severely active UC are similar with the exception of a few considerations in which the data exist specifically for a patient with moderately active UC:] a. 5-ASA therapy could be used as monotherapy for induction of moderately but not severely active UC. b. In patients with moderately active UC, consider nonsystemic corticosteroids such as budesonide MMX before the use of systemic therapy. c. In patients with severely active UC, consider systemic corticosteroids rather than topical corticosteroids. 23. Robust data on combination anti-tumor necrosis factor (TNF) and immunomodulator therapy in moderately to severely active UC exist only for infliximab and thiopurines. 24. Patients who are primary nonresponders to an anti-TNF (defined as lack of therapeutic benefit after induction despite adequate drug levels) should be evaluated and