Methotrexate Hepatotoxicity in Psoriasis — RACP Adult Medicine MCQ

Correct answer: C — Stop methotrexate and arrange hepatology assessment while selecting a non-hepatotoxic alternative psoriasis therapy

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

D is correct. Reproducibly high liver stiffness with supportive laboratory change raises concern for advanced fibrosis; ongoing methotrexate exposure should stop while hepatology defines stage and competing causes, and dermatology selects an alternative such as an appropriate biologic. E ignores objective toxicity because efficacy is good. A leaves the suspected injurious drug in place and waits for late decompensation. B reduces some methotrexate adverse effects but does not reverse established fibrosis or make continued exposure safe. C compounds risk. Cumulative dose alone is an imperfect predictor, but the decision here is driven by concordant evidence of liver injury, not by an arbitrary lifetime-dose threshold or an automatic requirement for biopsy before acting.

Reference: Australian Prescriber: Psoriasis—an update on topical and systemic therapies: https://australianprescriber.tg.org.au/articles/psoriasis-an-update-on-topical-and-systemic-therapies.html Australian RACP: Divisional Written Examination: https://www.racp.edu.au/trainees/examinations/divisional-written-examination