Most of us start treatment for RA with methotrexate. When your rheumatologist hands you the prescription, they usually do so with the statement "it is very important that you not drink alcohol while taking this medication." We get a lot of questions here on RAHealthCentral about methotrexate and alcohol. Why can't you drink while on this medication? Does that mean you can't even have a glass of champagne at a wedding? Are there other medications where you shouldn't drink alcohol? As the holiday season approaches, these questions are we set about finding the answers for you. I spoke to Dr. Yusuf Yazici of the NYU Langone Medical Center about RA meds and alcohol.
Why Methotrexate and Alcohol Don't Mix
"Methotrexate is cleared through the liver," Dr. Yazici explained. That means that the liver is the organ that processes or metabolizes the medication. One of the possible side effects when taking methotrexate is liver damage. "It can be caught very early in blood tests," Dr. Yazici said. This is why you pop in to see the vampires at the lab every six weeks to get blood drawn for a liver panel. Regular blood tests help your doctor keep an eye on your liver function and identify potential problems before they get serious. If the test shows signs of elevated liver enzymes, you stop taking methotrexate and your liver gradually goes back to normal.
Before methotrexate began to be used for RA, it was used by dermatologists to treat psoriasis. Dr. Yazici explained that historically, when methotrexate was used for psoriasis the recommendation was for patients to avoid alcohol completely. However, in rheumatology "studies show that it doesn't affect the liver as much in RA as for psoriasis. There are many more cases of the liver testing positive in psoriasis than in RA." Therefore, rheumatology is no longer following the old recommendations to completely abstain. Still, there is the potential for damage so Dr. Yazici said that these days, rheumatologists "still tell patients to watch it and to drink only for very occasional special events and one or two glasses at most."
I asked Dr. Yazici about the possible consequences of drinking while on methotrexate. He explained that in "psoriasis patients, you can get cirrhosis of the liver." He went on to say that "if you get damage, the liver can repair itself, but there is a threshold past which it can't repair itself. Then you have permanent liver damage." For people with RA, this is a worst-case scenario - regular blood tests will be able to catch potential problems before they get serious. Stopping the medication will allow your liver to heal itself. However, Dr. Yazici statements are a reminder to take your doctor's recommendations regarding alcohol consumption while taking methotrexate very seriously.
Other Meds and Alcohol
Methotrexate is not the only medication used to treat RA that is processed through the liver. Dr. Yazici explained that "rheumatologists use NSAIDs, methotrexate, leflunomide (Arava). These are all cleared through the liver and if something happens, they can cause damage to the liver in some patients." If you are on Arava for your RA, you will also have regular blood tests to check your liver function.
I asked Dr. Yazici if we should assume that the recommendation to only drink alcohol very occasionally applies to all medications that require regular liver function tests. He replied that it "is the safest way, it's what I recommend to my patients." In addition to methotrexate and Arava, Xeljanz, a new medication to treat RA, may also cause elevated liver enzymes. It's likely that the caution against alcohol consumption will also affect people who will take this drug. Dr. Yazici explained that the recommendation against drinking alcohol does not apply quite as much to the Biologics (Enbrel, Humira, Orencia, etc.), but that you should still be careful.
Dr. Yazici also explained that other medications used to treat RA are also cleared through the liver, i.e., NSAIDs (nonsteroidal anti-inflammatory drugs, such as naproxen, voltaren, Celebrex, etc.). Therefore, if you do take NSAIDs to address your symptoms of inflammation, you should also be very careful with alcohol.
And there's more. Dr. Yazici mentioned that "as patients age, they start taking other medications that also affect the liver. This means the potential for problems is higher." He also gave another example. "Patients may only be on methotrexate, but have an infection and get antibiotics. They get a cold and take cold medicine. Suddenly, they're on three medications that affect the liver. They're not thinking of the other ones as liver toxic and then they also drink." This is a valuable reminder to always be aware of the possible side effects and interactions of medication, both prescription and over-the-counter. Speak to your doctor or pharmacist to clarify whether you should be careful with particular medications.
What This Means for You
According to Dr. Yazici, recommendations for drinking while on methotrexate and other drugs that are processed through the liver have relaxed somewhat. Rheumatologists may now tell you that it is okay to have one or two drinks, very occasionally at special events. This doesn't mean every Friday night after work - although for many of us that is a pretty special event - but a glass of champagne at New Year's or a wedding is okay. However, you should be aware that this is a very general recommendation and your individual case may be different. If you have already experienced liver damage due to medication, illness or addiction in the past, your doctor may tell you to abstain completely. As Dr. Yazici mentioned, there is a threshold past which your liver may not be able to heal itself again.
Regardless of your past history, it's important that you speak to your rheumatologist, family doctor and pharmacist about the medications you take, both prescription and over-the-counter. Make sure you know about possible interactions with other medications, as well as side effects and cautions. Don't be afraid to be honest about a past history with substance abuse the more your doctor knows about you, the better they will be able to treat you. If you haven't had problems with alcohol or other addictive substances in the past, you should still be frank with your doctor about how you drink alcohol. If you have a glass of wine with dinner every day, your doctor will likely tell you to stop and find other ways of unwinding. In the big picture, getting your RA under control will be better for your physical and emotional health than a glass of wine.