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Rheumatoid arthritis — SCE Rheumatology MCQ

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ModerateInflammatory ArthritisRheumatoid arthritisSCE Rheumatology

A 58-year-old woman with seropositive rheumatoid arthritis is due to receive her seasonal inactivated influenza vaccination today. She takes methotrexate 20 mg once weekly as monotherapy. She has remained in low disease activity without glucocorticoids or a disease flare for 18 months. Her full blood count, liver biochemistry and renal function are normal. Which methotrexate plan is most appropriate to optimise vaccine response while maintaining disease control?

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Correct answer: E — Withhold methotrexate for 2 weeks after vaccination, then restart the usual dose

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 flare risk permit. This patient has sustained low disease activity without recent flares or glucocorticoid dependence, so a 2-week post-vaccination interruption is appropriate to optimise vaccine immunogenicity. Continuing methotrexate throughout is reasonable when the risk or consequences of a flare outweigh the anticipated improvement in vaccine response, but that is not the balance presented here. Dividing the interruption between the week before and the week after vaccination is not the recommended sequence: the evidence-based strategy is omission after vaccination. A 4-week interruption is unnecessarily prolonged and would expose her to greater flare risk without being the recommended methotrexate schedule. Influenza antibody titres are not routinely used to determine when methotrexate should be restarted, and waiting for serological confirmation could result in an indefinite and clinically unjustified treatment interruption.

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