The usual approach to treating ulcerative colitis (UC) is to start with the old standby medications, then gradually step up to more aggressive treatments as needed. But what if you flipped that approach upside down, starting with the most aggressive medications? That's a question more doctors have been asking lately. The Standard: Step-Up Approach The standard approach is to build up the treatment plan for UC step by step, based on how severe the symptoms are. The first step for mild to moderate symptoms is typically an aminosalicylate—a type of medication that helps decrease inflammation. Aminosalicylates can be effective for treating milder flare-ups and they can help prolong symptom-free periods in between. They're an affordable choice for many people, and some formulations have relatively few side effects. But these drugs may be no match for severe symptoms. The next step, when a more potent inflammation fighter is needed, is often a corticosteroid. Corticosteroids can get flare-ups under control within days. But because they can potentially cause harsh side effects—including high blood pressure, weakened bones, high blood sugar, cataracts, and psychiatric illness—they're typically used for only short periods of time. The next step, if required, may be to add an immunomodulator—a type of medication that suppresses the immune system. Immunomodulators can be combined with corticosteroids to treat flare-ups. They can also be continued long-term to help maintain symptom-free periods. They're a good choice for some people who have trouble with corticosteroid side effects. But they have their own risks, including hepatitis, pancreatitis, and an increased chance of infection. Plus, they're slow-acting and can require months to take effect. The next step, if required, may be infliximab (Remicade), golimumab (Simponi), vedolizumab (Entyvio), or adalimumab (Humira)—biologic medications that target a protein called TNF that promotes inflammation in the intestine. Unlike other medications, these TNF inhibitors go straight to the source of inflammation. They can help some people with UC even when other medications don't. Infliximab and vedolizumab must be taken by IV at a hospital or clinic every six to eight weeks. Adalimumab and golimumab may be given by injection at home. Possible side effects of both include an increased risk of serious infections, including tuberculosis, and increased risk of cancerous tumors. The Alternative: Top-Down Approach Some doctors now believe that certain people with UC might benefit from starting infliximab and immunomodulators early on, rather than waiting for symptoms to get worse. In this top-down approach, corticosteroids and aminosalicylates are introduced later only if needed. This approach is more common for treating Crohn's disease, another inflammatory bowel condition. But it's increasingly being discussed for UC as well. On the plus side, the top-down approach may reduce the need for corticosteroids—and therefore the risk of their side effects. It may also promote healing of tissues, better maintain symptom-free periods, and perhaps even prevent some complications of the disease. On the minus side, doctors still aren't sure who needs early aggressive treatment and who doesn't. Possible candidates include people younger than 40 and those with specific symptoms of UC, such as weight loss. Clinicians need to balance the benefits of early use of biologics with the potential risks of complications. More research is needed before top-down treatment is as accepted as step-up in treating UC. Key Takeaways The standard approach for ulcerative colitis is to build up the treatment plan step by step, based on the severity of symptoms. However, certain people might benefit from starting more aggressive medications early on. This "top-down" approach may have several benefits, but doctors still aren't sure who needs early aggressive treatment and who doesn't.