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Methotrexate Liver Monitoring — SCE Rheumatology MCQ

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HardRheumatoid ArthritisMethotrexate Liver MonitoringSCE Rheumatology

A 55-year-old man with active rheumatoid arthritis is about to start methotrexate. He has a BMI of 34 kg/m², type 2 diabetes mellitus and previously documented hepatic steatosis, but no clinical evidence of cirrhosis. His baseline transaminases and platelet count are within their reference ranges. In addition to standard pretreatment blood tests, which baseline strategy is recommended by current British Society for Rheumatology guidance to assess his risk of liver fibrosis?

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

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Correct answer: C — FIB-4 scoring, then elastography if indicated

The correct answer is C. Obesity, type 2 diabetes and hepatic steatosis are risk factors for liver disease. Current BSR csDMARD guidance recommends non-invasive FIB-4 assessment in adults with such risk factors when starting methotrexate, followed by elastography, such as FibroScan, when the result indicates that this is required. FIB-4 incorporates age, AST, ALT and platelet count; normal transaminases alone do not provide equivalent fibrosis risk stratification. The assessment should not unnecessarily delay methotrexate initiation. CT and portal Doppler ultrasonography are not the recommended initial fibrosis-screening pathway. An enhanced liver fibrosis test alone is not the strategy specified by BSR, while liver biopsy is invasive and is not appropriate as routine baseline screening. Standard methotrexate blood monitoring remains necessary and is not replaced by FIB-4.

Reference: British Society for Rheumatology. Updated csDMARDs guideline 2025 expands to all ages, Key recommendations. 17 November 2025. https://www.rheumatology.org.uk/news/details/Updated-csDMARDs-guideline-2025-expands-to-all-ages