17 November 2025
We have published an updated evidence-based clinical guideline on the safe use of conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) across the full spectrum of autoimmune rheumatic diseases.
Dr Louise Mercer, consultant rheumatologist at Stepping Hill Hospital, and Chair of the Guideline Working Group (GWG) explains why an update to the 2017 version was needed:
“The guideline reflects several changes in clinical practice since 2017, such as the inclusion of the csDMARD voclosporin, new evidence around optimising vaccine response in people taking methotrexate, and the introduction of a risk adaptive approach to blood monitoring.
Key recommendations:
- Following influenza or COVID-19 vaccination in adults, methotrexate should be withheld for up to two weeks, assuming disease activity / risk of flare allows. In the paediatric age group, this is up to the discretion of the clinician and an individualised approach is needed.
- Non-invasive scoring using a Fibrosis index (FIB-4) followed by an elastography (e.g. Fibroscan®) if indicated is recommended for adults with risk factors for liver disease when starting methotrexate, although this should not delay methotrexate initiation.
- During a severe infection, e.g. requiring intravenous therapy or hospitalisation, csDMARDs should be temporarily discontinued until the patient has recovered from the infection.
- Risk factors for DMARD toxicity should be reviewed at least annually, adjusting the frequency of monitoring according to the level of risk identified.
- The management of patients on csDMARD therapy should be a collaborative effort between primary care and specialist rheumatology providers. A shared care protocol should be agreed upon (including in the paediatric age group when shared care exists) delineating the responsibilities of each party.
The updated guideline, endorsed by Royal Pharmaceutical Society (RPS), includes the whole life course, providing guidance for the care of children and young people for the first time. Receiving input across the multi-disciplinary team (MDT), the GWG includes paediatric rheumatologists, paediatric pharmacists, and specialist nurses.
Dr Akhila Kavirayani, consultant paediatric rheumatologist at Oxford University Hospitals, said:
“Covering the whole life course enables seamless transition and thereby effective transfer of care to create a more cohesive and joined-up process between children and the adult services. This has a multitude of advantages in all facets of effective disease management; it not only empowers families and children and young people but also empowers clinicians across all tiers.”
Discussing how the updated guideline will improve nurse practice, Alan Davidson, clinical nurse specialist working in adult rheumatology in the community in Birmingham said:
“Nurses have and will always continue to play a key role in supporting patients with their medications, whether it's initiating or monitoring those. This guideline really helps give us clear evidence-based guidance and will enhance patient safety and provide consistency across the country”.
To complement the launch of the csDMARDs guideline we are pleased to be providing a new Guideline Collection, available on BSR e-learning, bringing together all guideline resources to support you with implementing the recommendations in practice.
Resources include:
- An exclusive video from GWG Chair, Dr Louise Mercer, at BSR Annual Conference 2025. (Available to watch in our elearning guideline collection)
- A Roundtable discussion video on the csDMARDs guideline, hosted by Editor-in-Chief of Rheumatology, Prof Ernest Choy
- csDMARDs infographic
- csDMARDs audit tool
- The full guideline and scope
All BSR guidelines and guideline resources are published in Rheumatology under an ‘open access’ licence and available for free via the BSR website.