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Rheumatoid arthritis — SCE Rheumatology MCQ

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ModerateACR GuidelinesRheumatoid arthritisSCE Rheumatology

A 54-year-old man with seropositive rheumatoid arthritis is treated with methotrexate 25 mg once weekly and etanercept 50 mg once weekly. He has remained in DAS28 remission for 12 months, has not required glucocorticoids and did not flare when methotrexate was omitted briefly during a previous holiday. He attends for his annual inactivated influenza vaccination. Both antirheumatic drugs are next due tomorrow, and he has no intercurrent infection. Which management plan is most consistent with current UK specialty guidance and concordant with the 2022 American College of Rheumatology vaccination guideline?

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

Reveal the answer and explanation

Correct answer: A — Vaccinate now, withhold methotrexate for 2 weeks afterwards and continue etanercept unchanged

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

Current British Society for Rheumatology guidance recommends withholding methotrexate for up to 2 weeks after influenza vaccination in adults when disease activity and flare risk permit. This patient’s sustained remission, absence of glucocorticoid dependence and previous tolerance of a brief interruption favour using that strategy. The ACR vaccination guideline similarly recommends a 2-week post-influenza-vaccination methotrexate interruption if disease activity allows, while continuing immunosuppressive treatments other than methotrexate and rituximab. Etanercept therefore continues on schedule. A is safe from a vaccine-administration perspective because the vaccine is non-live, but it forgoes the recommended opportunity to improve vaccine immunogenicity. B applies the interruption at the wrong time: the guideline-supported strategy is post-vaccination rather than a pre-vaccination methotrexate washout. D incorrectly selects the TNF inhibitor for interruption while continuing the drug specifically identified for withholding. E may appear to maximise vaccine response but adds an unsupported interruption of etanercept and increases the risk of loss of disease control. A randomised trial found that withholding methotrexate for 2 weeks after influenza vaccination increased satisfactory vaccine responses compared with continuation, without a significant increase in rheumatoid arthritis activity.

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 2022 American College of Rheumatology Guideline for Vaccinations in Patients With Rheumatic and Musculoskeletal Diseases (2023) — https://pubmed.ncbi.nlm.nih.gov/36597813/ 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/