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Methotrexate management around influenza vaccination — SCE Rheumatology MCQ

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ModerateRheumatoid ArthritisMethotrexate management around influenza vaccinationSCE Rheumatology

A 57-year-old woman with seropositive rheumatoid arthritis is established on methotrexate 20 mg once weekly. She has been in sustained remission for 18 months, has not required glucocorticoids during this period and has no history of flaring after brief treatment interruptions. She is due to receive the inactivated seasonal influenza vaccine on the same day as her next methotrexate dose and asks whether altering methotrexate would improve the vaccine response. What is the most appropriate advice?

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Correct answer: E — Withhold methotrexate for up to two weeks after vaccination and then restart at the usual dose

Explanation lettering: C = shown as B · B = shown as C

The 2025 British Society for Rheumatology csDMARD guideline recommends withholding methotrexate for up to two weeks following influenza or COVID-19 vaccination in adults, provided that disease activity and the risk of flare permit this. This patient has sustained remission, no recent glucocorticoid requirement and no history suggesting a high risk from brief interruption, so a post-vaccination hold is appropriate to optimise immunogenicity. A is reasonable when active disease or a substantial flare risk makes interruption undesirable, but it does not apply the updated recommendation in this stable patient. B is not a recommended vaccine-response strategy; dose reduction provides neither the defined interruption nor an established advantage. C places the interruption before vaccination, whereas the recommended timing is after vaccination, during the development of the vaccine response. D may enhance immunogenicity but unnecessarily doubles the recommended interruption and increases the opportunity for an RA flare. The vaccine is inactivated, so this is not a live-vaccine safety question: the rationale for withholding methotrexate is improvement of vaccine response rather than prevention of vaccine-derived infection.

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 The 2025 British Society for Rheumatology guideline for the prescription and monitoring of conventional synthetic disease-modifying anti-rheumatic drugs (2025 guideline; published 4 February 2026) — https://pubmed.ncbi.nlm.nih.gov/41235543/