Treat-to-target has become the organising framework for contemporary inflammatory bowel disease (IBD) management, yet its evidence base is less robust than its widespread endorsement might suggest. The approach rests on two equally essential pillars: defining the right therapeutic target, and adjusting treatment iteratively until that target is achieved. Over the past decade, the first pillar has advanced substantially: targets have deepened from symptomatic remission through endoscopic and histologic healing toward transmural and emerging molecular endpoints, supported largely by association data linking deeper remission to better long-term outcomes. The second pillar has received considerably less scrutiny. Completed randomised trials of iterative treatment adjustment have yielded mixed results in unselected populations, real-world monitoring remains inconsistent, and the most clinically pressing question, whether asymptomatic patients with residual inflammation benefit from optimising or switching advanced therapies, remains unanswered. In this review, we critically examine both pillars: the evolution and evidence base for treatment targets in IBD, the ability of current therapies to achieve them, the lessons from pivotal treat-to-target trials, and the barriers to real-world implementation. We propose a framework for individualising treat-to-target decisions based on disease history, inflammatory trajectory, therapeutic options, and patient preferences. Ongoing trials including QUOTIENT, VERDICT, and VECTORS may define whether the second pillar can be placed on as firm a footing as the first.
