For patients who do not have access to biologic therapies, what are some csDMARD combination pearls or tips that you have that have particular efficacy in different rheumatologic diseases?

I normally use MTX in RA. I initially aim for 15mg of MTX per week, then split the dose and maximize to 20-25mg/week. In some patients, I use SQ MTX if they have GI problems or are very obese. The addition of HCQ with MTX is better than MTX alone in some patients. I have rarely used SSZ+MTX+HCQ but it may be less well tolerated. In Canada, Rheumatologists have been using MTX+LEF with good results and acceptable toxicity. Biologics are more effective in patients with severe disease. However, csDMRDs alone or in combination, if properly used, can control a large number of patients with RA with good results, minimal damage, and acceptable toxicity.