Immunosuppressive and biologic therapies — branching viva

A branching viva following one child from the decision to start methotrexate in juvenile idiopathic arthritis through the weekly dose and folic acid, the full-blood-count and liver-enzyme monitoring, the weekly-versus-daily distinction, and the transition to an anti-tumour necrosis factor biologic with the dual tuberculosis screen and the live-vaccine rule.

branching clinical structured oral6 min readVerification in progress

Prompt

A six-year-old child with polyarticular juvenile idiopathic arthritis is to start methotrexate, and later progresses to an anti-tumour necrosis factor biologic. The examiner releases information in stages. The candidate must state the methotrexate schedule and monitoring, recognise the daily-dosing error, and build the pre-biologic screen and the live-vaccine plan.

Branching cross-examination

Name: Immunosuppressive and biologic therapies — branching viva
Creator: MedVellum
Published: 2026-07-17

This is a MedVellum formative viva. It is not an official RACP, MRCPCH, ABP, ACGME or RCPSC station, mark scheme, duration or pass standard. Release each update only after the candidate states the principle, the dose, and the safeguard. [5] [9]

Candidate brief

You are the paediatric registrar in a rheumatology joint clinic. Speak as you would when starting a child on methotrexate and later on a biologic. State the schedule, the safeguard, and the monitoring at each step. This is one continuous case. Each escalation branch leads to the next update. [5]

Paediatrics Fellowship Pro

You have read the opening of this viva. The complete unit — every section and its primary-source references — is part of the Paediatrics Fellowship fellowship atlas.

References6Show ledger

[1]Giannini EH; Brewer EJ; Kuzmina N Methotrexate in resistant juvenile rheumatoid arthritis. Results of the U.S.A.-U.S.S.R. double-blind, placebo-controlled trial. The Pediatric Rheumatology Collaborative Study Group and The Cooperative Children's Study Group The New England journal of medicine, 1992.PMID 1549149
[4]Foell D; Wulffraat N; Wedderburn LR Methotrexate withdrawal at 6 vs 12 months in juvenile idiopathic arthritis in remission: a randomized clinical trial JAMA, 2010.PMID 20371785
[5]Ferrara G; Mastrangelo G; Barone P Methotrexate in juvenile idiopathic arthritis: advice and recommendations from the MARAJIA expert consensus meeting Pediatric rheumatology online journal, 2018.PMID 29996864
[9]Calzada-Hernández J; Anton J; Martín de Carpi J Dual latent tuberculosis screening with tuberculin skin tests and QuantiFERON-TB assays before TNF-α inhibitor initiation in children in Spain European journal of pediatrics, 2023.PMID 36335186
[10]Parigi S; Licari A; Manti S Tuberculosis and TNF-α inhibitors in children: how to manage a fine balance Acta bio-medica : Atenei Parmensis, 2020.PMID 33004779
[11]Jansen MHA; Rondaan C; Legger GE EULAR/PRES recommendations for vaccination of paediatric patients with autoimmune inflammatory rheumatic diseases: update 2021 Annals of the rheumatic diseases, 2023.PMID 35725297