Today we’re taking a look at the latest American College of Gastroenterology (ACG) guidelines on managing Crohn’s disease in adults and comparing them to the previous version released in 2018. 

Managing patients with Crohn’s disease remains challenging due to its heterogeneous presentation and response outcomes to treatment options. Achieving remission requires close monitoring and personalized therapy. The ACG’s updated 2025 guidelines aim to help improve patient outcomes regarding this challenging disease.

There are a handful of notable changes between the two guidelines that are outlined below. In short, there are new treatment options recommended, a new visual summary, and changes to recommendations on combination therapy, treatment targets, biologic therapy, and more.

Guidelines Referenced:

Management of Crohn’s Disease in Adults, 2018

Management of Crohn’s Disease in Adults, 2025

Notable Key Takeaways in Recommendations, 2018 vs. 2025

Routine Laboratory Investigation Recommendations

  • 2018: “Fecal calprotectin is a helpful test that should be considered to help differentiate the presence of IBD from irritable bowel syndrome (strong recommendation, moderate level of evidence).”
  • 2025: “We recommend the use of FC (cutoff >50–100 μg/g) to differentiate inflammatory from noninflammatory disease of the colon (Strong recommendation; moderate level of evidence).”
  • Takeaway: The wording here shifts from fecal calprotectin being “helpful” to a more direct, “We recommend…” in the latest guidelines. Additionally, the addition of a cutoff value adds uniformity to the process to better diagnose a broader spectrum of conditions — not just irritable bowel syndrome.

Mild-to-Moderate Crohn’s Disease Recommendations – Budesonide

  • 2018: “Controlled ileal release budesonide at a dose of 9 mg once daily is effective and should be used for induction of symptomatic remission for patients with mild-to-moderate ileocecal Crohn's disease (strong recommendation, low level of evidence).”
  • 2025: “We recommend controlled ileal release budesonide at a dose of 9 mg daily for induction of symptomatic remission in patients with mildly to moderately active ileocecal CD (strong recommendation, moderate level of evidence). We recommend against the use of ileal release budesonide for maintenance of remission in patients with mildly to moderately active ileocecal CD (strong recommendation, low level of evidence).”
  • Takeaway: The updated guideline clearly recommends against budesonide for maintenance of remission. Additionally, the recommendation for 9 mg of ileal release budesonide daily was adjusted from low level of evidence to moderate level of evidence.

Moderate-to-Severe Crohn’s Disease Recommendations – Corticosteroids

  • 2018: “Oral corticosteroids are effective and can be used for short-term use in alleviating signs and symptoms of moderate to severely active Crohn's disease (strong recommendation, moderate level of evidence). Conventional corticosteroids do not consistently achieve mucosal healing and should be used sparingly (weak recommendation, low level of evidence).”
  • 2025: “We recommend oral corticosteroids for short-term induction of remission in patients with moderately to severely active CD (strong recommendation, low level of evidence).”
  • Takeaway: The adjusted phrasing around corticosteroid use reflects their limited long-term benefits and their associated risks. Both guidelines desire to keep corticosteroid use to short-term use, if necessary.

Immunomodulators Recommendations – Azathioprine and Mercaptopurine

  • 2018: “Azathioprine (at doses of 1.5–2.5 mg/kg/day) and 6-mercaptopurine (at doses of 0.75–1.5 mg/kg day) are not more effective than placebo to induce short-term symptomatic remission and should not be used in this manner (strong recommendation, low level of evidence). Thiopurines (azathioprine, 6-mercaptopurine) are effective and should be considered for use for steroid-sparing in Crohn's disease (Strong recommendation, low level of evidence). Azathioprine and 6-mercaptourine are effective therapies and should be considered for treatment of patients with Crohn's disease for maintenance of remission (strong recommendation, moderate level of evidence). Thiopurine methyltransferase (TPMT) testing should be considered before initial use of azathioprine or 6-mercaptopurine to treat patients with Crohn's disease (strong recommendation, low level of evidence).”
  • 2025: “We recommend against azathioprine (at doses of 1.5–2.5 mg/kg/d) and 6-mercaptopurine (at doses of 0.75–1.5 mg/kg/d) for induction of remission in moderately to severely active CD (strong recommendation, moderate level of evidence). We suggest azathioprine (at doses of 1.5–2.5 mg/kg/d) and 6-mercaptopurine (at doses of 0.75–1.5 mg/kg/d) for maintenance of remission in patients with moderately to severely active CD who had induction of remission with corticosteroids (conditional recommendation, low level of evidence). We recommend TPMT testing before initial use of azathioprine or 6-mercaptopurine to treat patients with CD (strong recommendation, low level of evidence).”
  • Takeaway: The clear recommendation against azathioprine and mercaptopurine, at their respective doses, for induction of remission is the clear key takeaway from this one. The recommendation for TPMT remains largely the same between the two guidelines.

Immunomodulators Recommendations – Methotrexate

  • 2018: Methotrexate (up to 25 mg once weekly IM or SC) is effective and should be considered for use in alleviating signs and symptoms in patients with steroid-dependent Crohn's disease and for maintaining remission (conditional recommendation, low level of evidence).
  • 2025: We suggest methotrexate (up to 25 mg once weekly intramuscular or subcutaneous) for maintenance of remission in patients with moderately to severely active CD who had induction of remission with corticosteroids (conditional recommendation, moderate level of evidence).
  • Takeaway: Here we see a slight bump in evidence level, from low level to moderate level. Also the 2018 mentions methotrexate for alleviating “signs and symptoms” and the updated 2025 version omits similar phrasing. 
Additional Comparisons Include:
  • The 2025 guidelines features a visual summary of highlights that the 2018 guidelines did not have.
  • The 2025 guidelines have 59 statements and 35 recommendations.
  • The 2018 guidelines have 53 statements and 60 recommendations.
  • The 2018 guidelines mentioned mesalamine as options for mild cases; the 2025 guidelines declare mesalmine has a limited benefit.
  • The endoscopy section was reduced from four recommendations in the 2018 version to one recommendation focusing on colorectal cancer screening.
  • Risankizumab is recommended in the 2025 update for induction and maintenance of remission. It was previously in development during the 2018 release.
  • Mirikizumab is also recommended in the 2025 update for induction and maintenance of remission in patients with moderate to severely active Crohn’s disease. There was no mention of mirikizumab in the 2018 guidelines.
  • Intravenous guselkumab is also recommended in the 2025 update. There was no mention of guselkumab in the 2018 guidelines.

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