THE British Society for Rheumatology (BSR) has released a major update to its evidence-based clinical guideline on the safe use of conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs), marking the first revision since 2017 and the first to cover the full life course, including children and young people. The update reflects significant shifts in prescribing practice, emerging data on immunomodulatory therapy, and a broader emphasis on risk-adaptive monitoring and shared care.
Changes Reflect Evolving Clinical Evidence
According to Louise Mercer, consultant rheumatologist at Stepping Hill Hospital and Chair of the Guideline Working Group, the revision was essential to incorporate evolving evidence, such as the addition of the csDMARD voclosporin, new recommendations on optimising vaccine responses in patients on methotrexate, and a more nuanced approach to blood monitoring tailored to individual risk. She noted that the refined guidance aims to improve safety while supporting treatment continuity.
Updated Guideline for Safer Prescribing
Among key updates, clinicians are advised that adults receiving influenza or COVID-19 vaccination may benefit from withholding methotrexate for up to two weeks when disease activity allows, based on evidence suggesting enhanced immunogenicity. A risk-stratified approach to detecting methotrexate-related liver disease is also recommended, beginning with non-invasive FIB-4 scoring and proceeding to elastography where indicated.
During severe infections requiring hospital care or intravenous therapy, csDMARDs should be stopped temporarily until recovery. The guideline also emphasises annual review of individual toxicity risk factors, with monitoring frequency adjusted accordingly, and reinforces the need for collaborative shared care arrangements between primary and specialist services.
Whole-Life-Course Guidance for Better Continuity
The update integrates paediatric rheumatology for the first time. Akhila Kavirayani, Oxford University Hospitals, highlighted that whole-life-course guidance strengthens transition between paediatric and adult services and enhances continuity of care. Nurses stand to benefit as well, with clinical nurse specialist Alan Davidson noting that the standardised recommendations will support consistent, safer prescribing and monitoring across the UK.
Reference
British Society for Rheumatology (BSR). Updated evidence-based clinical guideline on the safe use of csDMARDs across autoimmune rheumatic diseases. 2025. Available at: https://www.rheumatology.org.uk/. Last accessed: 1 December 2025.
