What are the STRIDE study treat-to-target recommendations for adult patients with inflammatory bowel disease?

STRIDE Study Treat-to-Target Recommendations for IBD

The STRIDE-II consensus (2021) establishes a comprehensive treat-to-target framework for IBD management with distinct short-term and long-term therapeutic goals that prioritize both objective disease control and patient-centered outcomes 1.

Long-Term Treatment Targets

The following represent the primary endpoints that should guide therapeutic decision-making:

For All IBD Patients:

• Clinical remission (corticosteroid-free for ≥8 weeks)
• Endoscopic healing - This is a core target
• Absence of disability
• Restoration of quality of life

Disease-Specific Endoscopic Definitions:

Ulcerative Colitis:

• Mayo endoscopic subscore of 0-1 2
• Clinical remission defined as resolution of rectal bleeding and diarrhea/altered bowel habit 2

Crohn's Disease:

• Simple Endoscopic Score for Crohn's Disease (SES-CD) <3 points, or absence of ulcerations 3
• Lewis score <135 on small bowel capsule endoscopy when applicable 3
• Clinical remission defined as PRO-2 (abdominal pain ≤1 and stool frequency ≤3) or Harvey-Bradshaw Index ≤4 3

Pediatric-Specific Target:

• Normal growth in children 1

Short-Term Treatment Targets

These serve as intermediate checkpoints during therapy:

• Symptomatic relief
• Normalization of biochemical markers:
  • C-reactive protein (CRP)
  • Erythrocyte sedimentation rate (ESR)
  • Fecal calprotectin 3, 1

Adjunctive Goals (Not Formal Targets)

Histological Healing:

• Ulcerative colitis: Should be assessed as a measure of remission depth, though not a formal treatment target 1
• Crohn's disease: Not currently recommended as a treatment target due to lack of consensus on definitions and limited therapeutic effectiveness 3

Transmural Healing:

• Crohn's disease only: Should be assessed through cross-sectional imaging (MRE or intestinal ultrasound) as a measure of remission depth, but not a formal target 3, 1

Monitoring Strategy

STRIDE-II endorses a multimodal approach combining 3:

1. Patient-reported outcomes (PRO-2 for Crohn's disease)
2. Biochemical monitoring (CRP, fecal calprotectin)
3. Endoscopic assessment (ileocolonoscopy)
4. Cross-sectional imaging when appropriate (MRE/intestinal ultrasound for Crohn's disease)

Fecal Calprotectin Interpretation Algorithm 3:

• <100 μg/g: Continue current therapy
• 100-250 μg/g: Intermediate probability of endoscopic remission; consider repeating in 6 weeks
• >250 μg/g or increase >50 μg/g: Low likelihood of endoscopic remission; consider endoscopic/radiological evaluation and therapy optimization

Critical Implementation Considerations

The 2025 British Society of Gastroenterology guidelines emphasize that frequency and type of monitoring depend on disease phenotype, therapy, and duration of remission 3. The CALM study demonstrated that achieving deep remission (clinical remission + mucosal healing without corticosteroids for ≥8 weeks) reduces risk of disease progression 3.

Common Pitfalls:

1. Symptom-inflammation mismatch: Up to 88% of patients in symptomatic remission may still have moderate-to-severe endoscopic inflammation 4. Never rely on symptoms alone.

2. Fecal calprotectin limitations: Correlation with endoscopic activity is weaker in isolated small bowel Crohn's disease compared to colonic disease 3.

3. Patient resistance to therapy escalation: Real-world data show 39% of patients prefer staying on current therapy despite not achieving endoscopic remission 4. Shared decision-making is essential.

4. Resource constraints: The 2025 BSG guidelines acknowledge that monitoring approaches must be adapted to local resources 3, though this should not compromise the fundamental goal of achieving endoscopic healing.

Quality of life and disability reduction are now formal long-term targets regardless of other inflammatory markers 3, reflecting the holistic nature of modern IBD management beyond purely biological endpoints.