Which is the second step in the established sequence of RA treatment?

• A. NSAIDs or MTX
• B. MTX + TNF
• C. MTX + Jak
• D. MTX alone

Answer: (B)

In RA, the treatment approach follows a stepwise, treat-to-target strategy. Methotrexate is the anchor disease-modifying option started early to control inflammation and slow joint damage. When disease activity remains moderate to high despite MTX alone, the next step is to add a biologic agent that targets TNF. This MTX plus TNF inhibitor combination provides a greater chance of achieving remission or low disease activity and better radiographic outcomes than MTX alone.

So the second step is to combine methotrexate with a TNF inhibitor. The alternative of using NSAIDs or relying on MTX monotherapy at this stage doesn’t address ongoing disease activity or progression as effectively, and while JAK inhibitors are valid options, they’re not considered the standard second-step escalation in the classic sequence.