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BSR 2025 WCC Threshold — SCE Rheumatology MCQ

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EasyRheumatology PharmacologyBSR 2025 WCC ThresholdSCE Rheumatology

A 60-year-old man with rheumatoid arthritis takes weekly oral methotrexate. Routine monitoring shows a white cell count of 3.0 × 10^9/L and neutrophils of 1.2 × 10^9/L; 3 months earlier these were 6.2 × 10^9/L and 3.8 × 10^9/L, respectively. He is afebrile and otherwise well. According to the 2025 British Society for Rheumatology csDMARD monitoring guideline, what is the most appropriate action?

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Correct answer: A — Interrupt methotrexate and contact the treating rheumatology team

The correct answer is A. His neutrophils are below 1.6 × 10^9/L and have fallen substantially from 3.8 × 10^9/L. The BSR 2025 monitoring table advises interrupting the csDMARD and contacting rheumatology when there is a significant fall. A small isolated change just below the lower limit of normal could be investigated and repeated after 2 weeks, but that does not describe this marked decline. Increasing folic acid does not adequately manage established neutropenia, and changing the route of methotrexate would not remove its marrow toxicity. The current BSR table does not use WCC below 3.5 × 10^9/L as a universal standalone stopping threshold.

Reference: British Society for Rheumatology. The 2025 British Society for Rheumatology guideline for the prescription and monitoring of conventional synthetic disease-modifying anti-rheumatic drugs, Table 5: Monitoring outcomes—actions required and paediatric considerations. 2025. https://www.rheumatology.org.uk/guidelines