Background: NICE guidance recommends the use of a combination of DMARDs, to include MTX, in the initial management of patients presenting with RA. Monotherapy is only recommended where there are contraindications or multiple comorbidities. However, it is not clear how frequently different treatment strategies are used in routine practice. The aim of this study was to identify, in a national observational cohort, the frequency of MTX monotherapy and examine factors associated with its prescription. Methods: The Rheumatoid Arthritis Medications Study (RAMS) recruited patients with RA starting MTX for the first time since 2008 across the UK. Patients included in this study presented within 2 years of symptom onset. Data, including demographics, comorbidity, medication history, smoking history, CRP, RF, DAS for 28 joints (DAS28) and HAQ were recorded at start of therapy. Subsequent medication changes were detailed at 3and 6-month follow up. Patients were classified as being on MTX monotherapy if they did not meet either of the following criteria: currently on another DMARD or another DMARD started within 90 days of MTX start date; and currently on oral steroids (for at least 30 days) or started on oral steroids within 30 days of MTX start date. Univariate and multivariate logistic regression analysed the association of MTX monotherapy with baseline age, gender, disease duration, CRP, RF, tender and swollen joint counts, HAQ, DAS28, smoking status and comorbidity. Results: A total of 731 patients were included, baseline characteristics are shown in Table 1. MTX monotherapy was prescribed in 493 (67%) patients, of those on combination treatment 193 (80%) were treated in combination with another DMARD, 48 (20%) with steroids. Older age was associated with increased odds of monotherapy and RF positivity with combination therapy (Table 1). Conclusion: MTX appears to be more commonly prescribed as monotherapy than in combination with other DMARDs, despite NICE guidance. In our study, older patients were more frequently treated with monotherapy; however no association was seen with the presence of multiple comorbidities. Others factors not currently incorporated within the guidance, such as patient preference, may be contributing to these prescribing practices. Disclosure statement: K.L.H. has received honoraria from AbbVie and Pfizer. All other authors have declared no conflicts of interest.