Treat-to-Target in Practice

Treat-to-target means setting clear IBD remission goals at the start of therapy, checking progress on a schedule, and adjusting treatment until those goals are met. The approach focuses on symptoms, inflammation markers in blood and stool, and healing seen on scopes or imaging. Used well, it reduces flares and complications and keeps steroid use short. (pubmed.ncbi.nlm.nih.gov)

Key takeaways

• Agree on measurable goals up front: symptom control, normal labs and stool tests, and mucosal healing on scope. (pubmed.ncbi.nlm.nih.gov)

• Checkpoints are time bound: early symptom response in weeks, biomarker improvement by 2 to 3 months, and endoscopic response by 3 to 6 months. (mdpi.com)

• Use fecal calprotectin as the main stool marker; many programs aim for 100 to 250 mcg/g as an interim target. (pmc.ncbi.nlm.nih.gov)

• If targets are missed, escalate or switch therapy, and use therapeutic drug monitoring with anti‑TNF agents when disease is active. (gastro.org)

• When symptoms persist but biomarkers are normal, look for noninflammatory causes such as IBS overlap or bile‑acid diarrhea, not just “more IBD.” (pubmed.ncbi.nlm.nih.gov)

What “treat-to-target” means day to day

The International Organization for the Study of IBD (IOIBD) STRIDE‑II framework defines short‑term targets and long‑term targets for Crohn’s disease and ulcerative colitis. Short‑term targets are symptom relief and normalization of C‑reactive protein (CRP) and fecal calprotectin. Long‑term targets are steroid‑free clinical remission and endoscopic healing. Histologic healing in ulcerative colitis and transmural healing in Crohn’s are supportive, not mandatory. (pubmed.ncbi.nlm.nih.gov)

Endoscopic healing means no visible ulcers. In ulcerative colitis, many teams accept a Mayo endoscopic subscore of 0 or 1, with complete endoscopic healing (0) linked to the best outcomes. In Crohn’s, targets often use SES‑CD thresholds, such as SES‑CD 0 to 2 without ulcers. (pmc.ncbi.nlm.nih.gov)

How clinicians set goals and timelines

A practical plan is written at treatment start:

1) Define targets
- Symptoms: normal stool frequency and no rectal bleeding in ulcerative colitis; resolved abdominal pain and near‑normal stool frequency in Crohn’s.
- Biomarkers: normal CRP and fecal calprotectin in an agreed range.
- Endoscopy or imaging: mucosal healing on scope, or, for Crohn’s, no ulcers and improved bowel wall on MRI or intestinal ultrasound. (pubmed.ncbi.nlm.nih.gov)

2) Decide when to check
- Symptoms weekly to monthly early on.
- Biomarkers about 8 to 12 weeks after starting or changing therapy, then every 3 to 6 months when stable.
- Scope at 3 to 6 months in ulcerative colitis, and 6 to 12 months in Crohn’s, or earlier if control is uncertain. Cross‑sectional imaging can substitute in ileal or stricturing Crohn’s. (mdpi.com)

Targets and timing at a glance

Evidence supports these intervals, but they are guides and may be individualized. (mdpi.com)

Using fecal calprotectin and CRP well

Fecal calprotectin tracks mucosal inflammation and correlates with endoscopic activity. Many programs aim for 100 to 250 mcg/g as an interim target during healing. Lower thresholds may predict deeper remission. Calprotectin values around 110 to 168 mcg/g often align with endoscopic healing in ulcerative colitis, while less than 250 mcg/g correlated with endoscopic improvement in Crohn’s in CALM analyses. (pmc.ncbi.nlm.nih.gov)

What happens when a checkpoint is missed

Treat‑to‑target is action oriented. Typical next steps include:

• Persistent symptoms and elevated biomarkers: escalate dose, shorten dosing interval, or switch class. Consider adding or optimizing rectal therapy in distal ulcerative colitis. (pubmed.ncbi.nlm.nih.gov)

• Symptoms but normal biomarkers: evaluate for functional symptoms, bile‑acid diarrhea, strictures, or pelvic floor problems. Do not escalate immune therapy without objective inflammation. (pubmed.ncbi.nlm.nih.gov)

• Biomarker rise without symptoms: repeat testing, look for triggers, and often act early to prevent relapse. (frontiersin.org)

• No endoscopic response by 3–6 months in ulcerative colitis, or 6–12 months in Crohn’s: intensify or switch therapy to pursue healing. (pmc.ncbi.nlm.nih.gov)

Tools that support adjustments

• Therapeutic drug monitoring (TDM). For patients on anti‑TNF therapy with active disease, reactive TDM helps decide whether to optimize dosing or switch. Routine proactive TDM remains debated in adults. (gastro.org)

• Intestinal ultrasound and MRI. These can show early transmural improvement in Crohn’s and reduce the need for frequent colonoscopy. (pubmed.ncbi.nlm.nih.gov)

• Home fecal calprotectin. Regular home testing can flag inflammation between clinic visits. (frontiersin.org)

What the evidence shows

In Crohn’s disease, a biomarker‑guided tight‑control strategy improved one‑year endoscopic healing and reduced hospitalizations compared with symptom‑driven care in the CALM trial, with longer‑term follow‑up linking deep remission at one year to fewer complications. (pubmed.ncbi.nlm.nih.gov)

Not every drug‑specific treat‑to‑target strategy is superior to standard care. In the STARDUST study of ustekinumab, algorithmic escalation based on early endoscopy and biomarkers did not outperform symptom‑driven dosing at 48 weeks, although quality of life improved in both groups and ultrasound changes tracked response. These results highlight that the framework is sound, but tactics vary by medicine and patient. (pubmed.ncbi.nlm.nih.gov)

A simple step‑by‑step workflow

1) Set targets and timepoints, and record baseline symptoms, labs, stool tests, and scope findings. (pubmed.ncbi.nlm.nih.gov)
2) Start therapy, confirm early symptom response within weeks. (mdpi.com)
3) Recheck CRP and fecal calprotectin at 8–12 weeks and act if abnormal. (mdpi.com)
4) Confirm healing on scope or imaging at 3–6 months in ulcerative colitis and 6–12 months in Crohn’s. (pmc.ncbi.nlm.nih.gov)
5) Maintain steroid‑free remission with periodic biomarker checks every 3–6 months, and reassess targets if life circumstances or risks change. (mdpi.com)

FAQs

What fecal calprotectin number is “good enough” while healing

Programs often use 100 to 250 mcg/g as an acceptable range during healing. Lower values tend to predict deeper remission. Final confirmation comes from endoscopy. (pmc.ncbi.nlm.nih.gov)

How soon is a scope repeated after starting treatment

Commonly at 3–6 months for ulcerative colitis and 6–12 months for Crohn’s, with imaging used when scoping is less practical in Crohn’s. (mdpi.com)

Are steroids a target

No. Steroids can control symptoms quickly, but treat‑to‑target focuses on steroid‑free remission with objective healing. (pubmed.ncbi.nlm.nih.gov)