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Methotrexate prescribing error — SCE Rheumatology MCQ

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EasyRheumatological PharmacologyMethotrexate prescribing errorSCE Rheumatology

A 72-year-old man with rheumatoid arthritis attends with mouth ulcers, bruising and diarrhoea. He was prescribed methotrexate 15 mg weekly but has taken it daily for 8 days. FBC shows neutrophils 0.4 × 10⁹/L and platelets 38 × 10⁹/L. Creatinine is mildly raised. What is the most appropriate management?

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Correct answer: A — Admit, stop methotrexate and give folinic acid rescue

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

Admit, stop methotrexate and give folinic acid rescue is best because daily methotrexate ingestion with mucositis and pancytopenia is life-threatening toxicity requiring urgent admission, cessation and folinic acid rescue. A is less suitable because adalimumab does not treat marrow suppression; B is less suitable because dose reduction is unsafe during acute toxicity; C is less suitable because standard folic acid dosing is inadequate for severe overdose; D is less suitable because delayed repeat testing risks sepsis and bleeding. Clinical pearl: methotrexate is prescribed weekly; daily dosing errors are a classic safety trap.

Reference: BNF; BSR csDMARD guideline 2025