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Methotrexate and RA-ILD — SCE Rheumatology MCQ

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HardRheumatoid ArthritisMethotrexate and RA-ILDSCE Rheumatology

A woman with rheumatoid arthritis has stable fibrotic ILD on serial HRCT and FVC, good joint control on methotrexate, and no temporal respiratory toxicity. She is referred solely because an old protocol states that any RA-ILD mandates methotrexate withdrawal. What is the best response?

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Reveal the answer and explanation

Correct answer: B — Continue methotrexate with serial clinical, lung-function and imaging surveillance

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

C is correct. Stable established lung disease is not an absolute contraindication to csDMARD treatment, and contemporary evidence does not show that methotrexate routinely causes de novo or progressive RA-ILD. The absence of a temporal toxicity syndrome and stable physiology favour preserving effective joint control while rheumatology and respiratory teams monitor symptoms and objective progression. A conflates chronic RA-ILD with acute methotrexate pneumonitis. B substitutes a medication with substantial cumulative harms. D makes antifibrotic therapy a prerequisite without evidence of progressive fibrosis. E turns an invasive diagnostic test into routine surveillance. New fever, hypoxaemia or diffuse inflammatory change would require methotrexate interruption and urgent reassessment, as tested separately in order 2.

Reference: 2025 BSR guideline for prescription and monitoring of conventional synthetic DMARDs: https://academic.oup.com/rheumatology/article/65/2/keaf522/8322743