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Methotrexate monitoring — SCE Rheumatology MCQ

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ModerateRheumatological PharmacologyMethotrexate monitoringSCE Rheumatology

A 58-year-old woman with rheumatoid arthritis takes methotrexate 20 mg weekly. Routine monitoring shows ALT 116 IU/L, twice the upper limit of normal, with normal bilirubin and albumin. She feels well and has no flare. Repeat bloods confirm the abnormality and she has recently started drinking more alcohol. What is the most appropriate management?

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

Reveal the answer and explanation

Correct answer: B — Withhold methotrexate and repeat LFTs urgently

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

Withhold methotrexate and repeat LFTs urgently is best because confirmed significant transaminitis during methotrexate therapy should prompt withholding the drug and reassessment for reversible causes. A is less suitable because waiting for symptoms misses clinically important drug toxicity; B is less suitable because leflunomide can also cause hepatotoxicity and would be unsafe here; C is less suitable because increasing folic acid alone is insufficient when liver enzymes are significantly abnormal; D is less suitable because rituximab is not an immediate response to an isolated monitoring abnormality. Clinical pearl: shared-care monitoring is designed to detect toxicity before symptoms appear.

Reference: BSR csDMARD guideline 2025; BNF