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Methotrexate pneumonitis — SCE Rheumatology MCQ

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ModerateRheumatological pharmacologyMethotrexate pneumonitisSCE Rheumatology

A 38-year-old woman has rheumatoid arthritis treated with methotrexate and develops dry cough and breathlessness. Examination shows oxygen saturations are reduced with fine basal crackles. Investigations show chest imaging shows diffuse interstitial infiltrates. The diagnosis is established and symptoms remain clinically important despite initial supportive measures. There is no contraindication to disease-modifying or anti-inflammatory escalation. What is the most appropriate management?

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

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Correct answer: B — Withhold methotrexate and arrange urgent assessment

Withhold methotrexate and arrange urgent assessment is the best answer because withhold methotrexate and arrange urgent assessment is the most appropriate next step for methotrexate pneumonitis in this clinical setting. Check full blood count and liver tests is a plausible distractor, but it does not account for the key discriminator in the stem. Arrange ophthalmology review and Stop leflunomide and consider washout would be more appropriate in a different clinical pattern or at another point in the pathway, while Prescribe bone protection is suboptimal for this presentation. Clinical pearl: rheumatology management is generally treat-to-target, but infection risk, pregnancy plans and shared-care monitoring often determine the safest answer.

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