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Rheumatoid arthritis — SCE Rheumatology MCQ

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ModerateMethotrexateRheumatoid arthritisSCE Rheumatology

A 58-year-old woman with seropositive rheumatoid arthritis takes oral methotrexate 20 mg once weekly. She has maintained remission for 14 months, with a current DAS28-CRP of 2.1, and has required no glucocorticoids during this period. Her renal function, liver biochemistry and full blood count are normal. She is due to receive an inactivated seasonal influenza vaccine next week and asks whether she should alter her methotrexate schedule to improve the vaccine response. She has not previously flared during brief treatment interruptions. Which methotrexate plan is most appropriate?

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

Reveal the answer and explanation

Correct answer: C — Withhold methotrexate for 2 weeks immediately after vaccination

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

The 2025 British Society for Rheumatology csDMARD guideline recommends withholding methotrexate for up to 2 weeks following influenza or COVID-19 vaccination in adults, provided disease activity and the risk of flare permit this. This patient has sustained remission, no recent glucocorticoid requirement and previous tolerance of brief interruptions, making a 2-week post-vaccination pause appropriate. ([rheumatology.org.uk](https://www.rheumatology.org.uk/news/details/Updated-csDMARDs-guideline-2025-expands-to-all-ages?utm_source=openai)) A randomised trial in rheumatoid arthritis found that withholding methotrexate for 2 weeks after influenza vaccination increased the satisfactory vaccine-response rate from 54.5% to 75.5%, without increasing measured rheumatoid arthritis disease activity. ([pubmed.ncbi.nlm.nih.gov](https://pubmed.ncbi.nlm.nih.gov/29572291/?utm_source=openai)) Continuing treatment (A) avoids interruption but forgoes the potential improvement in immunogenicity; it may be preferred when flare risk is high. A 1-week pause (B) may be an individualised compromise when a longer interruption is undesirable, but the stated low flare risk supports the guideline maximum. Withholding treatment before vaccination (D) does not follow the recommended timing or the principal trial protocol. A 4-week interruption spanning both sides of vaccination (E) is unnecessarily prolonged and may increase flare risk without an established additional clinical benefit.

Reference: Updated csDMARDs guideline 2025 expands to all ages (17 November 2025) — https://www.rheumatology.org.uk/news/details/Updated-csDMARDs-guideline-2025-expands-to-all-ages Impact of temporary methotrexate discontinuation for 2 weeks on immunogenicity of seasonal influenza vaccination in patients with rheumatoid arthritis: a randomised clinical trial (2018) — https://pubmed.ncbi.nlm.nih.gov/29572291/