Moderate Alcohol Consumption Safe for Rheumatoid Arthritis Patients on Methotrexate

RA patients can consume up to 14 alcoholic beverages per week without increasing the risk of liver damage, but rates increase with increasing levels of alcohol consumption.

Consuming alcohol in moderation was deemed safe among patients with rheumatoid arthritis (RA) who take methotrexate (MTX).

Traditionally, patients with RA who take MTX are advised to limit or completely abstain from alcohol consumption due to concerns surrounding the potential risk of hepatotoxicity.

In 1994, the American College of Rheumatology release guidelines that recommended abstaining from alcohol with only occasional exceptions. More recent guidelines from the British Society for Rheumatology issued in 2008 suggested that patients taking MTX should limit their alcohol intake to well within the UK national recommendations—–14 units per week.

Despite these recommendations, there has been limited data to support these concerns.

In a study published in the Annals of the Rheumatic Diseases, investigators sought to quantify the risk of developing abnormal liver blood tests at different levels of alcohol consumption.

The retrospective, observational study used data from the Clinical Practice Research Datalink, a large electronic database of routinely collected medical records from primary care. The investigators used data on patients with RA who started MTX between 1987 and 2016.

The primary outcome was an episode of transaminitis, defined as alanine transaminase or aspartate aminotransferase levels 3 times the upper limit of normal or more.

Crude rates of transaminitis were calculated per 1000 person-years and categorized by weekly alcohol consumption in units. The investigators used Cox proportional hazard models to examine the association between alcohol consumption and time to first episode of transaminitis, both univariately and age and gender adjusted.

A total of 11,839 patients were included in the study with a mean age of 61 years. There were 530 first episodes of transaminitis that occurred in 47,090 person-years follow-up, giving a crude event rate of 11.26 per 1000 person-years.

Crude rates of transaminitis were found to be similar between patients who consumed any amount of alcohol and non-drinkers, at 10.08 and 10.64 per 1000 person-years. In the age- and gender-adjusted Cox model, there was no increased risk in the occurrence of transaminitis in drinkers compared with non-drinkers.

When treated as a continuous variable, each increased unit of alcohol consumed was associated with a higher risk of transaminitis. Consuming between 15 to 21 units of alcohol was associated with a potential increased risk of hepatotoxicity. However, drinking >21 units of alcohol per week significantly increased the rate of transaminitis.

The authors noted that doses of MTX were not included in the analysis, and that physicians should use caution in counseling patients on alcohol consumption when on higher doses of MTX.

“We have demonstrated that the risk of transaminitis in patients with RA taking MTX does increase with increasing levels of alcohol consumption,” the authors wrote. “However, the risk in those patients who consume £14 units of alcohol per week is no greater than those who do not drink alcohol.

“Inclusion of acceptable alcohol levels into clinical guidelines and patient information leaflets may help improve decision-making, clinical outcomes, reduce decision conflict, and improve overall quality of life.”