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Methotrexate Hepatotoxicity — SCE Rheumatology MCQ

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ModerateRheumatology PharmacologyMethotrexate HepatotoxicitySCE Rheumatology

A 55-year-old man with RA on Methotrexate develops abnormal LFTs: ALT 85 U/L (1.5x ULN) AST 72 U/L GGT 110 U/L. He consumes 10 units of alcohol per week. According to BSR 2025 what is the recommended action?

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Correct answer: B — Continue Methotrexate and recheck LFTs in 2-4 weeks; if persistently elevated above 2x ULN withhold

BSR 2025 csDMARD guidelines recommend that transient mild LFT elevations (up to 2x ULN) can be monitored with repeat testing in 2-4 weeks. Persistent elevation above 2x ULN on two consecutive tests warrants withholding Methotrexate. Other causes should be investigated (alcohol, other hepatotoxic drugs, fatty liver, viral hepatitis). Alcohol consumption should be minimised on Methotrexate though complete abstinence is no longer mandatory per the updated guidance. LFTs should normalise before cautious reintroduction at a lower dose.

Reference: BSR 2025 - Guideline for prescription and monitoring of conventional synthetic DMARDs