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Shared Care Agreements — SCE Rheumatology MCQ

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HardRheumatology PharmacologyShared Care AgreementsSCE Rheumatology

A patient on stable methotrexate has platelets 228, 174 and 96 ×10^9/L on three successive monthly tests. Haemoglobin and neutrophils are stable, there is no bleeding and the laboratory lower limit is 150. What is the most appropriate response under the current BSR csDMARD guideline?

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Correct answer: E — Interrupt methotrexate, contact the rheumatology team and investigate the significant downward trend and alternative causes

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

D is correct. The 2025 BSR approach is not the obsolete pair of universal 150/100 thresholds reproduced in the frozen item. Platelets below the local lower limit with a significant fall should prompt temporary interruption, specialist contact and evaluation of trend and context. A dangerously ignores a fall of more than 50%. B invents a dependency on mean platelet volume. C applies an inappropriate monitoring interval. E converts a safety interruption into permanent withdrawal before reversible causes or spurious thrombocytopenia have been assessed. A minor value just below the lower limit without a significant trend can be repeated in about two weeks, but 228 to 96 is not a minor fluctuation.

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