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Acute severe ulcerative colitis occurs in up to 25% of patients with ulcerative colitis (UC). Therapeutic approaches have evolved in recent years with an increase in the use of biotherapies and in the number of treatments approved for moderate-to-severe UC. In this review, we summarize the latest evidence regarding short- and long-term medical strategies for severe acute colitis. In addition to standard care procedures—such as venous thromboembolism (VTE) prophylaxis, screening for triggers and aggravating factors, and close monitoring—the first-line treatment for severe acute colitis remains intravenous corticosteroids. Second-line therapies include infliximab and ciclosporin, which have similar short- and long-term colectomy rates. Pre-treatment exposure is key to guiding the choice of short- and long-term therapies in the context of severe acute colitis: In patients exposed to anti-TNF, calcineurin inhibitors may be preferred as a bridge therapy to vedolizumab or ustekinumab. Increasing evidence also supports the use of tofacitinib and anti-JAK in severe acute colitis. Finally, we will present future therapeutic perspectives, including novel combination therapies. A visual abstract summarizing these medical strategies is provided with this review.