This is a real-world medical entrance exam question, please give the true answer based on the question and selection. Topic name: NSAIDs, Gout and Rheumatoid Ahritis, Subject name: Pharmacology
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? 
Select and explain. 
A. Sta monotherapy with anti-TNF alpha drugs, B. Continue Methotrexate and steroids, C. Stop oral Methotrexate and sta parenteral Methotrexate, D. Add Sulfasalazine
D: Add Sulfasalazine
Answer: D: Add Sulfasalazine 
Explanation: 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.