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considered for alternative mechanisms of disease control (e.g., in a different class of therapy) rather than cycling to another drug within the anti-TNF class. 25. In patients with moderately to severely active UC who had an initial response but subsequently lost efficacy to one anti-TNF therapy, we recommend alternative anti-TNF therapy (but not the biosimilar to the original brand) compared with no treatment for induction of remission. 26. The patient with nonresponse or loss of response to therapy should be assessed with therapeutic drug monitoring to identify the reason for lack of response and whether to optimize the existing therapy or to select an alternate therapy. 27. Obtain consultation with a surgeon and consider colectomy in patients with moderately to severely active UC who are refractory or intolerant to medical therapy. Recommendations 19. In patients with moderately active UC, we recommend oral budesonide MMX for induction of remission (strong recommendation, moderate quality of evidence). 20. In patients with moderately to severely active UC of any extent, we recommend oral systemic corticosteroids to induce remission (strong recommendation, moderate quality of evidence). 21. In patients with moderately to severely active UC, we recommend against monotherapy with thiopurines or methotrexate for induction of remission (strong recommendation, low quality of evidence). 22. In patients with moderately to severely active UC, we recommend anti-TNF therapy using adalimumab, golimumab, or infliximab for induction of remission (strong recommendation, high quality of evidence). 23. In patients with moderately to severely active UC who have failed 5-ASA therapy and in whom anti-TNF therapy is used for induction of remission, we suggest against using 5-ASA for added clinical efficacy (conditional recommendation, low quality of evidence). 24. When infliximab is used as induction therapy for patients with moderately to severely active UC, we recommend combination therapy with a thiopurine (strong recommendation, moderate quality of evidence for azathioprine). 25. In patients with moderately to severely active UC, we recommend vedolizumab for induction of remission (strong recommendation, moderate quality of evidence). 26. In patients with moderately to severely active UC who have previously failed anti-TNF therapy, we recommend vedolizumab for induction of remission (strong recommendation, moderate quality of evidence). 27. In patients with moderately to severely active UC, we recommend tofacitinib 10 mg orally b.i.d. for 8 weeks to induce remission (strong recommendation, moderate quality of evidence). 28. In patients with moderately to severely active UC who have previously failed anti-TNF therapy, we recommend tofacitinib for induction of remission (strong recommendation, moderate quality of evidence). 29. In patients with moderately to severely active UC who are responders to anti-TNF therapy and now losing response, we suggest measuring serum drug levels and antibodies (if there is not a therapeutic level) to assess the reason for loss of response (conditional recommendation, very low quality of evidence). Summary of evidence Treatment with 5-ASA therapy has been shown to be efficacious and safe as monotherapy for induction of moderately but not severely active UC. One meta-analysis showed that patients with moderately active disease benefited from treatment with 2.4 g/d, whereas corticosteroid therapy remained more effective for patients with severe disease (97).