The pharmacologic management of ulcerative colitis and Crohn's disease is usually carried out in a stepwise fashion. Initially, oral sulfasalazine or 5-aminosalicylic acid (5-ASA) products are given and, for patients with rectal disease, treatment may include topical therapy with either 5-ASA enemas or hydrocortisone suppositories. Patients with more active inflammatory disorders may also require oral corticosteroid therapy. Patients with fulminant disease may require intravenous steroids and antibiotic therapy. If frequent relapses prevent discontinuation or significant reduction of prednisone therapy, azathioprine or 6-mercaptopurine may offer benefit as steroid-sparing agents. Also, intravenous cyclosporine has proved useful in patients with fulminant inflammatory bowel disease that is unresponsive to other therapy. Metronidazole has value in the treatment of perianal disease secondary to Crohn's disease. Balancing the risks and benefits of single or combination therapy is an ongoing challenge in patients with inflammatory bowel disease.