A rheumatoid Ahritis 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?

For patient with RA, Steroid and NSAIDS one given for symptomatic relief. Methotrexate used alone or in combination therapy has become a mainstay of treatment in patient with RA or psoriatic ahritis. Methotrexate is a folic acid antagonist that inhibits cytokine production and purine nucleotide biosynthesis leading to immunosuppressive and anti-inflammatory effects. If methotrexate alone is not working, We add sulfasalazine, If it still doesn't work, we give triple therapy which are:- Methotrexate Sulfasalazine Hydroxychloroquine/ Leflunomide If triple therapy doesn't work, we Sta INF inhibitor.