Level of agreement: a-81%, b-19%, c-0%, d-0%, e-0% Quality of evidence: II-2 Classification of recommendation: C Leukocytapheresis removes inflammatory cells from peripheral blood in order to provide anti-inflammatory and immunomodulatory effects. Two apheresis systems are available for the treatment of UC—the Adacolumn apheresis system (JIMRO Co. Ltd, Takasaki, www.selleckchem.com/products/AZD1152-HQPA.html Japan),137 which employs a single-use

column containing cellulose acetate beads that removes 65% of neutrophils, 55% monocytes, and 2% lymphocytes from the peripheral blood, and the Cellsorba FX leukocytapheresis column (Asahi Medical, Tokyo, Japan),138 which removes 100% of neutrophils and monocytes, and 20–60% lymphocytes by adsorption to a hydrophilic polypropylene column. A course of treatment is typically 5–10 sessions at intervals of 1–2 weeks. Sessions last an hour, during which time 2–3 L of blood is drawn from one arm, filtered, and infused into the other arm.137–139 Data from Japan has shown promising results. In steroid-naive patients (patients on only 5-ASA) with severe UC, various studies collectively have reported a remission

rate between 71 and 88%. The response and remission rates in steroid-refractory or steroid-dependent disease using the Adacolumn system has varied between 43% to 92% and 21–92%, respectively.139,140 In contrast, a multicenter, sham-controlled trial conducted in the US and a smaller study of identical design conducted in Europe and Japan141 failed to show benefit www.selleckchem.com/products/CAL-101.html of leukocytapheresis.

The discrepancy between Western and Asian trial data remains unexplained.142 Antibiotics as monotherapy have not been shown to improve active ulcerative colitis. Level of agreement: a-60%, b-40%, c-0%, d-0%, e-0% Quality of evidence: I Classification of recommendation: A The benefit of antibiotics in the primary or adjunctive treatment of IBD has not been established in randomized controlled trials. Studies have been limited by poor study design, small patient numbers, high ifenprodil dropout rates and heterogeneity in entry criteria, concomitant therapies, and endpoints. The majority of the data do not support the use of antibiotics as primary treatment or as an adjunct to standard corticosteroid therapy of mild to moderate or severe UC. However, broad-spectrum antibiotics are reasonable to consider in patients with fulminant colitis, such as toxic megacolon at risk of perforation, especially if these patients are also receiving corticosteroids.143 Immunomodulators such as thiopurines [IA] or biologics [II-2,B] can be recommended for treating steroid-dependent, steroid-refractory or relapsing ulcerative colitis. There is currently only limited evidence for the use of methotrexate in ulcerative colitis [III,C]. Calcineurin inhibitors are used short-term as a bridge to another immunomodulator such as a thiopurine [II-2,B].