The following patient on Methotrexate, steroids and NSAIDs for past 4 months has had no retardation of disease progression. What is the next rational step in management?

Z-line deformity, ulnar detion: RHEUMATOID AHRITIS Option A: Combination with Methotrexate, cannot be given alone. Option B: Steroids are not proved to reduce the occurrence of R.A nowadays. Steroids may lead to increase of Cushing syndrome Option C: Parenteral treatment is not recommended Combination therapy where appropriate; (3) individualization of therapy in an attempt to maximize response and minimize side effects; and (4) achieving, whenever possible, remission of clinical disease activity. A considerable amount of evidence suppos this intensive treatment approach. As mentioned earlier, methotrexate is the DMADRD of the first choice for initial treatment of moderate to severe RA. Failure to achieve adequate improvement with methotrexate therapy calls for a change in DMARD therapy, usually a transition to an effective combination regimen. Effective combination include: methotrexate, sulfasalazine, and hydroxychloroquine (oral triple therapy); methotrexate and leflunomide; and methotrexate plus a biological. The combination of methotrexate and an anti-TNF agent, for example, has been shown in randomized, controlled trails to be superior to methotrexate alone not only reducing signs and symptoms of disease, but also for retarding the progression of structural joint damage.