Inflammatory Bowel Disease: Why Treatment Has Changed

For many years, the treatment of inflammatory bowel disease (IBD), mainly Crohn’s disease and ulcerative colitis, followed a step-up approach. Treatment would often begin with medications considered less intensive, while stronger therapies were introduced only if symptoms persisted or complications developed.

Today, this approach has changed significantly.

The goal of treatment is no longer simply to make patients feel better. Whenever possible, we aim to effectively control inflammation, achieve sustained remission, avoid repeated courses of corticosteroids, prevent bowel damage, and preserve quality of life over the long term.[1–3]

Controlling symptoms is not enough

One of the most important lessons learned over the past decades is that symptoms and intestinal inflammation do not always go hand in hand.

A person with Crohn’s disease, for example, may have relatively few symptoms while inflammation continues in the intestine and gradually leads to complications such as narrowing of the bowel, fistulas, abscesses, or the need for surgery.

For this reason, modern IBD care follows a strategy known as treat-to-target. This means that, in addition to symptom improvement, treatment response is assessed using objective measures of inflammation. These may include blood tests, fecal calprotectin, endoscopy, and, in selected situations, imaging tests.

According to the international STRIDE-II recommendations, long-term treatment goals include clinical remission, healing of the intestinal lining, improved quality of life, and reducing the impact of IBD on daily activities.[3]

This represents an important change in perspective: successful treatment should not be assessed only by the number of bowel movements or the presence or absence of abdominal pain.

Crohn’s disease: preventing inflammation from causing bowel damage

Crohn’s disease can be progressive. Persistent inflammation over time may cause scarring and narrowing of the bowel, fistulas, other complications, and eventually the need for intestinal surgery.

The 2024 guidelines from the European Crohn’s and Colitis Organisation (ECCO) emphasize the importance of early diagnosis, timely treatment, and close monitoring of treatment response.[1]

For patients with moderate-to-severe Crohn’s disease, ECCO recommends several advanced therapies to induce and maintain remission. This represents an important shift away from the older approach of waiting for several less effective treatments to fail before considering more effective options.

Delaying an effective treatment in a patient with a higher-risk form of Crohn’s disease may have consequences that go beyond persistent symptoms.

What about ulcerative colitis?

Ulcerative colitis requires a somewhat different approach.

The updated ECCO guideline for the medical treatment of ulcerative colitis, published in July 2026, continues to recommend 5-aminosalicylates as an important treatment for many patients with mild-to-moderate disease. For patients with moderate-to-severe ulcerative colitis, however, several advanced therapies are recommended for achieving and maintaining remission.[2]

Corticosteroids may still play an important role in controlling an active flare in selected situations, but they are not appropriate as long-term maintenance treatment. The need for repeated courses of corticosteroids, steroid dependence, or difficulty maintaining remission should prompt a reassessment of the treatment strategy.

It is also important to remember that Crohn’s disease and ulcerative colitis are different conditions, and each may require an individualized approach to treatment.[2]

What are advanced therapies?

Advanced therapies are medications designed to control specific mechanisms involved in the inflammation that causes IBD.

They include different types of biologic medications as well as newer oral therapies. Because these treatments work in different ways, having several options allows treatment to be better tailored to each patient.

There is no single medication that is best for everyone.

The choice of treatment depends on several factors, including:

• the severity, location, and behavior of the disease;
• treatments previously used and how the patient responded to them;
• symptoms or inflammatory conditions outside the intestine;
• age and other health conditions;
• safety considerations and risk of infections;
• pregnancy planning;
• patient preferences;
• how the medication is administered and how often it needs to be taken;
• how quickly the disease needs to be controlled.

For this reason, two people with the same diagnosis may receive very different treatments while both are being treated according to the best available scientific evidence.

The ultimate goal is to give patients control of their lives

Remission should mean more than simply having fewer symptoms.

Today, treatment goals include living without dependence on corticosteroids, achieving objective control of inflammation, preventing hospitalizations and complications whenever possible, and allowing IBD to interfere as little as possible with work, studies, travel, physical activity, relationships, and social life.

For patients with moderate-to-severe IBD, using a sufficiently effective treatment at the right time may be just as important as choosing which treatment to use.

Modern IBD care is therefore becoming less focused on reacting to complications after they occur and more focused on preventing them by controlling inflammation, monitoring the disease, and adjusting treatment when therapeutic goals are not achieved.

References

1. Gordon H, Minozzi S, Kopylov U, et al. ECCO Guidelines on Therapeutics in Crohn’s Disease: Medical Treatment. Journal of Crohn’s and Colitis. 2024;18(10):1531-1555. doi:10.1093/ecco-jcc/jjae091.
2. Gisbert JP, Chaparro M, Verstockt B, et al. ECCO Guidelines on Therapeutics in Ulcerative Colitis: Medical Treatment. Journal of Crohn’s and Colitis. 2026;20(7):jjag066. doi:10.1093/ecco-jcc/jjag066.
3. Turner D, Ricciuto A, Lewis A, et al. STRIDE-II: An Update on the Selecting Therapeutic Targets in Inflammatory Bowel Disease Initiative of the IOIBD. Gastroenterology. 2021;160(5):1570-1583. doi:10.1053/j.gastro.2020.12.031.

This content is intended for educational purposes and does not replace individualized medical assessment. Treatment decisions in inflammatory bowel disease should take into account disease activity and behavior, previous treatments, other health conditions, safety considerations, and each patient’s individual preferences.