Your patient with rheumatoid arthritis has not responded to corticosteroids. What should you consider as the next step?

In the management of rheumatoid arthritis, when a patient has not responded to corticosteroids, the next step typically involves considering disease-modifying anti-rheumatic drugs (DMARDs). Methotrexate is the cornerstone of DMARD therapy for rheumatoid arthritis and is particularly effective in preventing joint damage and reducing disease activity.

Starting methotrexate at this stage is appropriate because it has a strong evidence base supporting its use for patients who do not have an adequate response to corticosteroids alone. Methotrexate not only helps control inflammation but also has a favorable side effect profile compared with biologic therapies, particularly for patients who may be at risk for infections or other complications.

While biologic therapy is a highly effective option for patients who are inadequately controlled, it is often considered in cases of severe disease or when multiple DMARDs have been unsuccessful. Increasing the corticosteroid dosage is generally not advisable due to potential adverse effects associated with higher doses. Referral to a rheumatologist is useful for complex cases or if the condition is severe, but starting methotrexate would be a more immediate next step in management. Thus, methotrexate is a logical choice for addressing the inadequate response in this scenario.