Therapeutic approaches in inflammatory bowel disease (IBD) involve targeting the broad inflammatory process, targeting specific inflammatory mediators, changing the interior milieu to diminish antigenic drive, or removing the main mediators of inflammation, the inflammatory cells, completely. Recent developments have occurred in each of these therapeutic areas. New steroids, and better use of existing drugs, such as azathioprine and cyclosporin, have improved therapy. Genetically engineered drugs, such as TNF-alpha antibody, offer the prospect of powerful treatment for patients resistant to standard therapies. The use of probiotics offers an entirely new approach, by changing the lumenal milieu. Understanding how bacteria and epithelial cells interact is likely to bring important rewards in therapy. Finally, immune cell replacement may be a possible therapy for severe disease when all else has failed.