How do you approach oral DMARD and/or biologic selection in patients with RA and a history of gastric bypass or whom are planning bariatric surgery?

Very interesting and important question. It is important to remember gastric bypass patients, depending on the type of intervention, can change the absorption of a host of medications, so it is a challenge to know if a lack of response is from poor efficacy or poor absorption, therefore poor bodily exposure.

I employ two strategies with these patients:

1. Pick medications for which you can obtain a blood or serum level. There are commercial laboratories for hydroxychloroquine levels, methotrexate metabolites, cyclosporine levels, and in some sites leflunomide levels/metabolites that can tell the prescriber if the drug is being placed into circulation.
2. Use parenteral forms over oral formulations. Subcutaneous (sQ) methotrexate is easy to admin...