BACKGROUND: The treatment options for chronic inflammatory bowel diseases (IBD) have been greatly expanded due to a better understanding of the underlying pathogenesis. A total of five classes of advanced treatment are available. OBJECTIVE: A practical overview of advanced treatment of IBD. METHODS: Narrative review. RESULTS AND DISCUSSION: Advanced treatments are indicated for moderate to severe IBD. A timely use is recommended to achieve better response rates and to avoid irreversible bowel damage. Tumor necrosis factor (TNF) inhibitors and Janus kinase (JAK) inhibitors have a broad efficacy, also for extraintestinal disease manifestations. The risk of reactivation of varicella zoster virus is increased with JAK inhibitors. In high-risk patients and an age >
65 years there is possibly a moderately elevated cardiovascular risk and neoplastic side effects. The integrin alpha4beta7 inhibitor vedolizumab and the interleukin (IL) 12 and 23 inhibitor ustekinumab have very good safety profiles. Selective IL-23 inhibitors are sometimes superior to ustekinumab with comparable safety profiles with respect to efficacy. The sphingosine-1-phosphate receptor modulators ozanimod and etrasimod are approved for oral treatment of ulcerative colitis. The treatment success of the medications remains still limited and a minority of patients will not respond to every individual treatment. Thus, sequential administration of several treatments is often needed. Due to the lack of comparative studies, the personalized choice, sequence and decision for treatments are usually based on personal experience and should take patient preferences, efficacy, safety and individual patient profiles into consideration.