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Methotrexate Monitoring — MRCGP AKT MCQ

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HardRheumatologyMethotrexate MonitoringMRCGP AKTUKMLAPARAPSA

A patient on stable methotrexate has white cell counts of 6.8, 5.1, 4.2 and 3.7 ×10⁹/L over four monitoring visits. Neutrophils are 1.8 ×10⁹/L and the patient is well. What is the best interpretation?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: B — Repeat promptly and discuss the downward trend with the specialist team

Explanation lettering: E = shown as A · D = shown as C · C = shown as D · A = shown as E

B is correct. SPS emphasises monitoring trends as well as absolute thresholds. A steady fall from 6.8 to 3.7 ×10⁹/L may represent evolving marrow suppression even though the latest count is just above a commonly used withholding threshold. The result should be repeated promptly, the full differential and other trends reviewed, and the specialist or shared-care team contacted about whether methotrexate should be withheld. Waiting for symptoms or a further fall can miss early toxicity. Increasing the dose is unsafe, and iron deficiency does not explain an isolated progressive leukocyte decline.

Reference: NHS Specialist Pharmacy Service, methotrexate monitoring: https://www.sps.nhs.uk/monitorings/methotrexate-monitoring/