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Topical NSAIDs First-Line OA — SCE Rheumatology MCQ

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HardOsteoarthritisTopical NSAIDs First-Line OASCE Rheumatology

A 54-year-old with well-controlled rheumatoid arthritis takes methotrexate 20 mg weekly and is due seasonal influenza vaccination. Her flare risk is judged low. Which advice is supported by the 2025 BSR csDMARD guideline to improve vaccine response?

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

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Correct answer: D — Give the vaccine and consider withholding methotrexate for up to two weeks afterwards, with an agreed flare plan

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

E is correct. For influenza and COVID-19 vaccination, current BSR guidance permits methotrexate to be withheld for up to two weeks after vaccination when disease activity and individual flare risk allow; vaccination itself should not be delayed unnecessarily. A falsely labels injected influenza vaccines as live. B uses an excessive pre-vaccination interruption and non-routine antibody testing. C invents dose doubling and ignores evidence that a brief post-vaccine pause can improve response. D substitutes immunosuppression with its own infection and metabolic harms. The recommendation is conditional rather than automatic: patients with unstable disease may reasonably continue methotrexate, making shared planning more accurate than a blanket rule.

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