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Methotrexate toxicity — SCE Rheumatology MCQ

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HardRheumatological pharmacologyMethotrexate toxicitySCE Rheumatology

A 63-year-old woman has inflammatory musculoskeletal symptoms evolving over several weeks with features suggestive of methotrexate toxicity. Examination shows there is objective synovitis or organ involvement on examination. Investigations show targeted investigations support an immune-mediated rheumatological disorder. The team is planning baseline risk assessment and follow-up surveillance. The current consultation focuses on preventing morbidity rather than changing the diagnosis. What is the most important complication to screen for?

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Correct answer: A — Bone marrow suppression

Bone marrow suppression is the best answer because methotrexate toxicity is associated with bone marrow suppression, which may be clinically silent until advanced. Severe infection is a plausible distractor, but it does not account for the key discriminator in the stem. Uveitis and Renal involvement would be more appropriate in a different clinical pattern or at another point in the pathway, while Interstitial pneumonitis is suboptimal for this presentation. Clinical pearl: screening is most valuable when it detects a complication that is common, serious and clinically silent early in its course.

Reference: BSR csDMARD monitoring guideline; BSR biologic/targeted DMARD safety guideline; BNF