Treat-to-Target in Practice

Treat-to-target is a way of managing Crohn’s disease and ulcerative colitis that uses clear, shared goals and regular checks to guide treatment changes. Instead of reacting only when symptoms spike, the care team decides on specific targets, tracks symptoms and objective tests over time, and adjusts medicines until those targets are reached and maintained. This approach aims to reduce flares, complications, and disability over the long term.

Key takeaways

• Treat-to-target starts with agreeing on concrete goals, like symptom control, normal tests, and healed bowel lining.

• Short-term targets focus on feeling better; medium- and long-term targets focus on quiet inflammation and protecting the gut.

• Progress is followed using symptom reports, blood and stool markers, scopes, imaging, and sometimes drug level tests.

• If targets are not met, clinicians usually first check adherence and triggers, then adjust dose or switch to another medicine.

• The plan is always individualized; guidelines give a framework, but decisions depend on risks, preferences, age, and access.

What “treat-to-target” means in real life

In inflammatory bowel disease, treating only when symptoms flare can leave “silent” inflammation smoldering, which increases the risk of strictures, fistulas, surgery, and disability over time. Treat-to-target was developed to address this problem.

International expert groups (STRIDE and STRIDE-II) recommend using predefined treatment targets, checking progress at set intervals, and changing therapy in a structured way until those targets are reached.(mayoclinic.elsevierpure.com)

The strategy is similar in Crohn’s disease and ulcerative colitis, but the exact tests and timing may differ, depending on which parts of the gut are involved and how severe disease is.

Setting the targets together

Guidelines divide targets into short-, medium-, and long-term goals. Clinicians then adapt these to each person’s situation.(pubmed.ncbi.nlm.nih.gov)

Short-term targets (weeks to a few months) often include:

• Clear improvement in bowel symptoms, like less pain, fewer loose stools, less bleeding, and reduced urgency.

• Better overall wellbeing, energy, appetite, and sleep.

Medium-term targets (about 3–6 months) usually focus on early signs that inflammation is settling:

• Blood markers of inflammation returning to normal, especially C-reactive protein (CRP) when it was high at baseline.

• Stool fecal calprotectin falling into an acceptable range, often around 100–250 µg/g, depending on the guideline and context.(comet-initiative.org)

Long-term targets (6–12 months and beyond) are aimed at durable remission and protection from damage:

• Clinical remission, meaning no or minimal bowel symptoms.

• Endoscopic healing on colonoscopy or, for parts of the small bowel that cannot be seen directly, healing on imaging.(mayoclinic.elsevierpure.com)

• Good quality of life, minimal disability, and for children, normal growth and development.(pubmed.ncbi.nlm.nih.gov)

Examples of targets in practice

*Exact thresholds can differ by guideline, lab, and clinical situation.

How clinicians track progress

Treat-to-target needs regular, structured monitoring. This is sometimes called “tight control.”(wjgnet.com)

Symptom tracking and clinic visits

At each visit, the care team asks about:

• Stool frequency, consistency, and urgency.

• Visible blood or mucus.

• Abdominal pain, bloating, weight change, fatigue, fevers.

Clinicians may use formal scores, but simple, consistent questions over time are often just as important. Symptom improvement is the first success marker, but symptoms alone are not enough to judge inflammation.(pubmed.ncbi.nlm.nih.gov)

During active disease, many guidelines suggest visits about every 3 months, then every 6–12 months once stable remission is reached.(wjgnet.com)

Blood and stool biomarkers

CRP in blood and fecal calprotectin in stool provide noninvasive windows into inflammation. STRIDE-II and newer AGA guidelines recommend using these regularly, alongside symptoms, to decide whether treatment is working.(comet-initiative.org)

Typical patterns in a treat-to-target plan:

• During active disease or after starting a new therapy, biomarkers may be checked every 2–3 months.(wjgnet.com)

• If symptoms improve but biomarkers stay high, clinicians consider intensifying treatment or arranging a scope.

• If biomarkers rise again in someone who feels well, they may repeat the tests, look for infections, or do endoscopy to catch a quiet flare early.(pubmed.ncbi.nlm.nih.gov)

Biomarkers are not perfect. Some people with active disease have normal CRP, and fecal calprotectin can be affected by other conditions. Results are always interpreted alongside symptoms and other tests.

Endoscopy and imaging

Colonoscopy or flexible sigmoidoscopy is key for confirming mucosal healing, which is a central long-term target.(mayoclinic.elsevierpure.com)

In ulcerative colitis, clinicians look for a smooth, pink lining without ulcers or friability. In Crohn’s disease, scopes and cross‑sectional imaging (such as MR enterography) help confirm that ulcers and deep inflammation have resolved, especially in the small intestine.

Guidelines often suggest a follow‑up scope 6–12 months after starting a new advanced therapy, then less often if deep remission is maintained. Timing depends on how severe disease was, the treatments used, and cancer surveillance needs.(wjgnet.com)

Quality of life and function

Treat-to-target frameworks now include quality of life, daily function, and, for children, growth as formal goals.(pubmed.ncbi.nlm.nih.gov)

Clinicians may ask about:

• Ability to attend work or school reliably.

• Social and family activities, mood, and anxiety.

• Sleep, fatigue, and any pain between flares.

Simple questionnaires or app‑based tracking can help capture this information over time.

How therapy is adjusted when targets are not met

When targets are not being reached, clinicians usually move through a stepwise thinking process rather than immediately switching drugs.

Common steps include:

1. Confirming the problem
   - Review symptoms, recent infections, other medications (like NSAIDs), and lab or scope results.

2. Checking adherence and practical barriers
   - Ask whether doses have been missed, infusions delayed, or instructions unclear.

3. Using therapeutic drug monitoring (TDM) when relevant
   - For biologics and thiopurines, blood tests can show drug levels and antibodies. AGA and expert panels support reactive TDM when disease is active, to decide whether to increase the dose, change interval, or switch therapies.(gastro.org)

4. Optimizing the current drug
   - Increase dose or shorten dosing intervals, add a companion drug (for example, a short steroid course, rectal therapy in UC, or an immunomodulator if appropriate), and recheck biomarkers and symptoms after several weeks.(pmc.ncbi.nlm.nih.gov)

5. Switching mechanism or route if needed
   - If drug levels are high but inflammation continues, this suggests “mechanistic failure,” and the team often switches to a medicine with a different mode of action.

The CALM trial in Crohn’s disease showed that tight control, using symptoms plus biomarkers to trigger stepwise adalimumab escalation, led to higher rates of endoscopic healing than symptom‑based decisions alone.(pubmed.ncbi.nlm.nih.gov) This supports the idea that proactive adjustments based on objective inflammation can improve outcomes.

Practical limits and real‑world challenges

Surveys of gastroenterologists show strong support for treat-to-target goals, but also note real barriers. These include disagreement about how to define “mucosal healing,” limited access to frequent biomarkers or scopes, high out‑of‑pocket costs, and complex Crohn’s complications such as fistulas.(pubmed.ncbi.nlm.nih.gov)

Because of this, clinicians often adapt the framework to local resources and individual circumstances. Some may lean more on biomarkers when endoscopy access is limited; others may prioritize symptom and quality‑of‑life goals for people with severe anxiety, other health conditions, or pregnancy.(pubmed.ncbi.nlm.nih.gov)

Throughout, treat-to-target works best as a partnership, with people living with IBD, families, and the care team agreeing on realistic targets, monitoring plans, and how aggressive to be in adjusting therapy over time.

FAQs

Why are symptoms alone not enough for treat-to-target?

Symptoms and inflammation do not always match. Some people feel well but have ongoing silent inflammation, which raises the risk of future bowel damage. Others have symptoms from scarring, IBS, or bile acid problems even when inflammation is quiet. Using biomarkers and scopes alongside symptoms helps the team decide whether to change IBD therapy or look for other causes.(pubmed.ncbi.nlm.nih.gov)

How often are tests needed in a treat-to-target plan?

During active disease or after starting a new medicine, many programs review symptoms and biomarkers every 2–3 months and do a scope within about 6–12 months to check healing. Once stable deep remission is confirmed, visits and tests are usually spaced out, often to every 6–12 months, with flexibility based on risk factors and any new symptoms.(wjgnet.com)