Which immunosuppressors do you use to treat Crohn's disease and ulcerative colitis? In which order of priority and how worried are you about toxicity?

In severe and steroid-refractory UC, intravenous cyclosporin A is an effective tool to induce rapid remission. Short-term side effects can be dealt with, and decisions on further treatment can be made without emergency. AZA/6-MP can be used in steroid-dependent or chronically active disease and probably to maintain cyclosporin A-induced remission if surgery is not possible or not accepted. The latter should be discussed with the patient and an experienced surgeon. Other immunosuppressors do not play a role in my approach to this disease. In CD, AZA/6-MP is useful for steroid-refractory and -dependent patients. Again toxicity is limited and can be handled. This treatment should be used more frequently and is my approach of choice if fibrous stenoses, as cause of chronic activity, are excluded. MTX can be used as second-line treatment. I am worried about its long-term toxicity, in particular to the liver, as described in rheumatic disorders. Both intravenous cyclosporin A and AZA/6-MP should be used by those having experience with these drugs (and IBD). They are much needed and helpful.