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Methotrexate intolerance — SCE Rheumatology MCQ

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ModerateRheumatoid arthritisMethotrexate intoleranceSCE Rheumatology

A 43-year-old woman with RA has good joint control on methotrexate but develops severe nausea and mouth ulcers after each weekly dose. Examination shows no synovitis is present. Investigations show FBC and LFTs are normal and she takes folic acid 5 mg once weekly. What is the most appropriate management?

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Correct answer: D — Increase folic acid and consider subcutaneous methotrexate

Folate optimisation and changing to subcutaneous methotrexate are reasonable first measures for gastrointestinal intolerance when blood tests are stable. Switching straight to rituximab would bypass conventional measures and does not match UK biologic sequencing. Trimethoprim with methotrexate increases marrow toxicity risk and should be avoided unless specialist advice supports it.

Reference: NICE NG100; BSR biologic DMARD safety guideline; BNF