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BSR 2025 ALT Action Threshold — SCE Rheumatology MCQ

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EasyRheumatology PharmacologyBSR 2025 ALT Action ThresholdSCE Rheumatology

A 50-year-old man with RA on Methotrexate attends for blood monitoring. His ALT is 3.5 times the upper limit of normal on two consecutive tests 4 weeks apart. Hepatitis screen is negative and he reports minimal alcohol intake. According to BSR 2025 what is the recommended action?

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Correct answer: A — Withhold Methotrexate if ALT is persistently >2x ULN on two tests; investigate alternative causes and do not restart until ALT normalises then restart at reduced dose

BSR 2025 csDMARD guidelines provide clear action thresholds for liver enzyme abnormalities: ALT/AST persistently >2x ULN on two consecutive tests warrants withholding Methotrexate. Other causes should be investigated (alcohol viral hepatitis fatty liver drug interactions). The drug should not be restarted until transaminases have normalised. When restarting use a reduced dose with more frequent monitoring. If ALT >3x ULN with symptoms (jaundice abdominal pain) or >5x ULN urgent specialist hepatology review is needed. FIB-4 scoring and elastography should be considered for patients with persistent LFT abnormalities or liver disease risk factors.

Reference: BSR 2025 csDMARD guidelines