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Psoriatic arthritis with metabolic risk factors for liver disease — SCE Rheumatology MCQ

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ModerateMethotrexatePsoriatic arthritis with metabolic risk factors for liver diseaseSCE Rheumatology

A 52-year-old woman with active peripheral psoriatic arthritis is to start methotrexate after an inadequate response to non-steroidal anti-inflammatory drugs and local glucocorticoid injections. She has a body mass index of 36 kg/m², type 2 diabetes mellitus and dyslipidaemia. She drinks 4 units of alcohol weekly. Alanine aminotransferase, aspartate aminotransferase, albumin, bilirubin and platelet count are normal. Viral hepatitis screening is negative, and there are no clinical features of advanced chronic liver disease. Which approach to baseline liver fibrosis assessment is most appropriate?

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

Reveal the answer and explanation

Correct answer: D — Calculate FIB-4 now, start methotrexate without waiting, and arrange elastography if indicated

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

Her obesity, type 2 diabetes and dyslipidaemia are risk factors for metabolic liver disease despite normal transaminases. Current BSR guidance recommends non-invasive fibrosis assessment in adults with liver disease risk factors when starting methotrexate. The sequence is initial FIB-4 calculation, followed by elastography if the result or clinical context indicates this. The assessment should not unnecessarily delay methotrexate initiation. A is incorrect because liver biopsy is invasive and is not a routine baseline investigation; it may be considered by hepatology when non-invasive assessment is discordant or diagnostic uncertainty remains. C recognises the relevance of fibrosis assessment but incorrectly applies elastography universally and makes treatment contingent on its completion. D is attractive because her routine liver biochemistry is normal, but normal transaminases do not remove the need for risk-based fibrosis assessment. E is incorrect because conventional ultrasonography may demonstrate steatosis or structural abnormalities but cannot reliably exclude clinically important fibrosis and does not replace the recommended FIB-4-to-elastography pathway.

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