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Risk-Adaptive DMARD Monitoring — SCE Rheumatology MCQ

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ModerateRheumatoid ArthritisRisk-Adaptive DMARD MonitoringSCE Rheumatology

A 60-year-old man with rheumatoid arthritis has received a stable dose of methotrexate for 3 years under a shared-care agreement. Serial full blood counts, renal function and liver transaminases have been normal. He has no previous DMARD toxicity, renal or liver impairment, relevant comorbidity, or newly introduced interacting medicines. Which ongoing laboratory-monitoring approach best accords with current British Society for Rheumatology guidance?

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

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Correct answer: C — Review toxicity risk at least annually and individualise the monitoring interval, with less frequent monitoring for persistently low-risk patients

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

B is correct. The 2025 BSR csDMARD guideline replaces a uniform lifelong monitoring schedule with risk-adaptive blood monitoring. DMARD-toxicity risk factors should be reviewed at least annually, and the testing interval adjusted to the risk identified. This patient is persistently stable and has no stated toxicity risk factors, so a less frequent interval can be considered following individualised assessment. Scheduled monitoring should not cease: methotrexate-related cytopenia, hepatotoxicity and renal impairment may be clinically silent. Monthly testing is unnecessarily intensive in a stable low-risk patient. Conversely, a fixed 3-monthly schedule without reassessing risk does not reflect the risk-adaptive approach. Symptom-triggered monitoring alone is unsafe.

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