@ibddocmaria @IBDMD @vipuljairath @JoanaTo62523004 @silvio_silvio75 @PeyrinBiroulet @FernandoMagro6 @ibdseb.

@UriKopylov @Y_ECCO_IBD @bverstockt @maria_chs @ManasiAgrawalMD @MariangelaAllo3 @RajaAtreya @BattatMD4IBD @BettenworthDb @AlaaEl_Hussuna @ellul_pierre @GionataFiorino @jp_gisbert @JoaoPGSabino @HolubarStefan @MariettaIacucci @TakuKobayashiM1 @pakotze @HenitYanaiMD.

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Finally, as ever, although I know how the headline recommendations sometimes get reproduced, the recommendations themselves should not be read isolated from the supporting text - that’s where the most important information is to be found.

Most importantly, these guidelines are NOT rules. Patients will not fit into exact groups and we stress the importance of individualisation. This is not an argument against guidelines - the evidence base is a starting point for generating patient-specific recommendations.

A limitation because our guidelines cannot address country or region specific needs. I welcome and enjoy reading local guidelines that address country-specific needs and circumstances - they act as an adjunct not a competitor. Points of difference generate valuable debate.

But do we need “yet more” or multiple guidelines? ECCO guidelines are unique in IBD in terms of international makeup (again, 19 countries, 4 continents) and reach. This is a strength & a limitation. Strong because we generate shared understanding from international talent pool.

The guidelines remain a valuable point of reference for contemporary management of CD, especially for those who may not be seeing patients with IBD all day or every day. I have seen ECCO guidelines bookmarked on clinic computers around the world.

Also a contribution to keeping field (inc. pharma) focussed on what takes to get an intervention endorsed &how data must be generated to build use case above what regulators demand. Particularly true where H2H studies performed -these are recognised with specific recommendations.

Why does this matter? It’s fair to ask what we should do with the output. At one level, the guidelines may not tell us much new (approved drugs are endorsed within their licensed indications - so what?) But not all findings are so obvious and there is still much nuance.

The surgical teams did a great job of taking fistula recommendations right back to drawing board, reflecting changes in practice and evidence. They also discussed changes in surgical approaches to enteral disease &to surgical case management within the wider MDT.

In terms of nomenclature, we have removed any references to “conventional” therapy from our work - the group felt strongly that these terms are outdated and poorly reflect contemporary practice or the appropriateness of treatments available to patients.

We also discuss dietary therapies. GRADE-approaches have limitations when applied to the relevant literature, but as well as formal GRADE recommendations on EEN, we were able to include extensive practice points and discussion on the use of dietary therapies. @BonehRotem.

In the medical paper we discuss strategies for treatment escalation but also de-escalation, particularly around the de-escalation of specific anti-TNF therapies in combination with immunomodulators.

We chose not to use NMA as a sole basis for any recommendations - group felt this was a useful tool in decision making, but not appropriate for use in isolation as a basis for recommendations, particularly given inherent limitations and assumptions.

What’s new? Clearly we appraise new drugs, but also try to provide guidance on how to select between them. This includes direct H2H data where available, but we discuss nuances of selection in absence of direct comparison.

After at least 2 rounds of voting, recommendations were then further reviewed in half-day meetings within medical and surgical working groups, before being presented (and defended) in a final full day consensus meeting.

Evidence was presented to the consensus group as draft recommendations or practice points, with explanatory text. Preliminary voting rounds were held within the authorship group, but also input from national representatives and other expert volunteers to help shape the consensus.

The evidence was then reviewed by authors and expert methodologists to assess the extent to which it answered the pre-formulated questions. All evidence was reviewed for quality according to standardised processes.

Evidence: for questions &outcomes we were keeping unchanged from previous efforts, we updated prior literature searches for new material since last guidelines. New questions needed new systematic reviews. All search terms &extraction processes published in full transparent manner.

We also included important, common practical questions with broader scope &more limited evidence than GRADE typically supports. We developed “practice points” distinct from formal recommendations, but still formulated in advance, subject to literature reviews &voting processes.