Alcohol and Methotrexate:  How concerned should I be?

One of the most frequent questions that I get asked by my patients who are about to start Methotrexate is: “What about alcohol”.

We are aware that Methotrexate may rarely be associated with liver toxicity and that alcohol in excess may be injurious to the liver. Many of us may be reluctant however to give up the pleasure of an occasional glass of wine or other fine alcoholic beverage on special (or perhaps not so special) occasions. Moreover, clinical studies have shown that alcohol in moderation (especially in the case of red wine) may be beneficial to our overall health. What does the scientific literature have to say about the issue of alcohol and Methotrexate?

Unfortunately, aside from general agreement about the potential for increased liver injury in patients who indulge in alcohol while on Methotrexate, the issue has never been systematically evaluated. The key question as to the actual risk of liver damage relative to the amount of alcohol ingested and the Methotrexate dose remains unanswered. Thus, practical concerns such as whether there is a safe amount of alcohol that one may drink; whether there is a difference between the type of alcohol ingested (i.e. wine versus hard liquor versus beer); or whether the timing of the drinking relative to the taking of the Methotrexate is important – are difficult if not impossible to answer.

The challenge in predicting the risk of liver injury is further complicated by individual patient factors such as prior drinking history, the preexisting health of the liver, age, body weight and coexisting conditions such as diabetes, psoriasis as well as the other medications that you may be taking. Any one or all of these factors may act in combination with alcohol and Methotrexate to increase the risk of liver damage.

Thus, it is not at all surprising that there is no consensus regarding the use of alcohol and Methotrexate. Guidelines vary from complete abstinence to suggestions recommending a “stringent reduction” in preexisting alcohol usage. Where alcohol may be allowed, recommendations range from one or two drinks per month (the American College of Rheumatology) to one or two drinks per week (the Canadian Rheumatology Association). In all cases careful and continuing monitoring of the liver blood tests is emphasized.

There are additional considerations regarding the use of alcohol in arthritis patients. In a small but significant minority of patients alcohol may actually lead to a temporary worsening of pain and stiffness. Also, since many arthritis patients are also on anti-inflammatory medications such as NSAIDS or Prednisone, alcohol can interact with these medications to increase the risk of other problems such as esophageal and stomach irritation or even ulceration.

It is important to remember that your Rheumatologist will consider your alcohol usage as just one element of a comprehensive screening process to ensure that it is safe for you to take Methotrexate. This includes a careful history of other medical conditions such as diabetes, obesity, psoriasis, preexisting liver, blood, kidney or lung abnormalities, risk of infection, and concurrent medication. He or she will also arrange for a complete battery of baseline lab tests. Any one or combination of abnormalities detected by the above screening process could limit or in fact prevent you from taking Methotrexate for safety reasons.

What is my personal policy? After undertaking a careful clinical and laboratory screening as outlined above, I have a frank and open discussion with my patients in which I strongly discourage the use of alcohol while on Methotrexate. For patients who indulge, I recommend that alcohol be ideally restricted to special occasions only and never more than one to two glasses per week. Some patients who drink alcoholic beverages regularly and who are unwilling to stop or significantly reduce their alcohol intake may not be candidates for Methotrexate. It is important to clearly determine and adhere to the recommendation of your Rheumatologist regarding alcohol and Methotrexate as policies may vary from practitioner to practitioner and from center to center.

In conclusion, consuming alcohol while taking Methotrexate may put your liver at risk for liver damage and cirrhosis. Although some patients may be able to get away with a few drinks once in a while, individual susceptibility to liver injury is highly variable and unpredictable and may relate to a number of other factors. Always be honest with your doctor about the use of alcohol and finally, remember to report on a regular basis for lab testing to ensure the continued safety of your Methotrexate therapy.