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Folic Acid BSR 2025 — SCE Rheumatology MCQ

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EasyRheumatology PharmacologyFolic Acid BSR 2025SCE Rheumatology

A 60-year-old man with seropositive rheumatoid arthritis is established on oral methotrexate 15 mg once weekly, taken every Monday. He has normal renal and liver function and no cytopenias, and he asks what folate supplementation he should take. According to current British Society for Rheumatology csDMARD guidance and UK practice, which regimen should be prescribed?

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

Reveal the answer and explanation

Correct answer: B — Folic acid 5 mg once weekly, taken on a day other than the methotrexate day

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

BSR guidance is that everyone taking methotrexate is co-prescribed folic acid at a minimum dose of 5 mg once weekly, and UK shared-care protocols direct that it be taken on a day other than the methotrexate day; hence B. Folate reduces gastrointestinal intolerance, stomatitis and transaminitis, and does not meaningfully impair efficacy at these doses. A is wrong because supplementation is routine, not reserved for abnormal bloods. C is wrong: folinic acid is rescue therapy for significant methotrexate toxicity or overdose, not routine co-prescription. D is wrong because macrocytosis is a late marker, and prophylaxis should start with methotrexate. E gives a subtherapeutic total weekly dose and dosing on the methotrexate day is avoided in UK practice; higher-frequency 5 mg regimens (not 1 mg daily) are the recognised escalation for persistent intolerance.

Reference: NHS Specialist Pharmacy Service. Using folic acid with methotrexate in rheumatoid arthritis (BSR recommendation: minimum folic acid 5 mg once weekly), current. https://sps.nhs.uk/articles/using-folic-acid-with-methotrexate-in-rheumatoid-arthritis/