<prompt> 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?Sta monotherapy with anti-TNF alpha drugsContinue Methotrexate and steroidsStop oral Methotrexate and sta parenteral MethotrexateAdd Sulfasalazine  <response>: 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 doesnt work, we give triple therapy which are:- Methotrexate Sulfasalazine Hydroxychloroquine Leflunomide If triple therapy doesnt work, we Sta INF inhibitor. 