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Methotrexate liver monitoring — SCE Rheumatology MCQ

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ModerateRheumatological pharmacologyMethotrexate liver monitoringSCE Rheumatology

A 36-year-old woman taking methotrexate for RA has ALT persistently 2.5 times the upper limit of normal on two tests. She drinks 25 units of alcohol weekly and BMI is 34 kg/m^2. What is the most appropriate management?

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Correct answer: B — Withhold methotrexate and assess hepatotoxicity risk factors

Persistent transaminase elevation on methotrexate should prompt withholding or dose adjustment according to shared-care thresholds and evaluation of risk factors such as alcohol and fatty liver disease. Adding leflunomide could worsen hepatotoxicity. Normal bilirubin does not make recurrent ALT elevation safe.

Reference: BSR csDMARD monitoring guideline 2025; BNF