It would be entirely appropriate to try sulfasalazine initially and to avoid both methotrexate and leflunomide until the patient is able to reduce his alcohol intake
It would be inappropriate to continue with the methotrexate at the current dose in this situation. All the other options are entirely reasonable including a hepatology review if the LFT abnormalities persist.
The use of a TNF inhibitor would be justified in many healthcare systems as he has failed treatment with conventional synthetics DMARDs. If there is limited or no access to biologics, then either leflunomide or parenteral methotrexate would be reasonable options.
There is very little risk of worsening of skin psoriasis with intra-articular and/or intra-muscular steroids, and this form of treatment would be entirely appropriate if that is what the patient wants to have. There would be concerns with the use of TNF inhibitor therapy because of his recent malignancy, and also he should not be forced to use any disease modifying medication because the patients' wishes are always paramount.
The most appropriate next course of action would be to trial apremilast. A non-TNF inhibitor bDMARD could be considered, but at present we do not have enough data regarding their use in patients with previous malignancy. Similarly, leflunomide or sucutaneous methotrexate could also be considered but the apremilast would be a better choice in this situation because of its lack of liver toxicity.
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