Methotrexate and Alcohol: A Dangerous Combination for RA Patients

The Effects of Methotrexate and Alcohol Consumption

Methotrexate is a common medication used to treat autoimmune diseases like rheumatoid arthritis. It works by suppressing the immune system and reducing inflammation. However, methotrexate can cause side effects, especially when combined with alcohol consumption. In this article, we'll examine the effects of mixing methotrexate and alcohol and provide tips for staying safe while taking this medication.

How Methotrexate Works

Methotrexate is classified as an antimetabolite medication. It works by inhibiting the metabolism of folic acid, which interferes with DNA and RNA synthesis. This effect slows down the growth and multiplication of cells in the body's immune system. By suppressing overactive immune cells, methotrexate can reduce inflammation and symptoms of autoimmune diseases.

Methotrexate is commonly prescribed in low weekly doses for conditions like:

• Rheumatoid arthritis
• Psoriasis
• Crohn's disease
• Multiple sclerosis
• Lupus

When used properly, methotrexate can greatly improve quality of life for people with these chronic inflammatory illnesses. However, the medication does carry a risk of side effects, especially when it interacts with alcohol.

Methotrexate and the Liver

One of the main risks with methotrexate is liver toxicity. Methotrexate is metabolized by the liver, so taking the medication long-term can damage liver tissue and impair liver function. Some signs of liver toxicity include:

• Jaundice
• Dark urine
• Abdominal pain
• Nausea and vomiting
• Fatigue

Alcohol is also broken down by the liver. When methotrexate and alcohol are combined, the liver has much more work to do. This increased strain makes liver injury more likely. Heavy alcohol consumption is especially risky but any amount of alcohol can potentially cause problems when taking methotrexate.

Increased Risk of Liver Fibrosis

Chronic liver toxicity from methotrexate can lead to liver fibrosis, which is scarring of the liver tissue. The formation of scar tissue impairs the liver's ability to function normally. People who drink alcohol while taking methotrexate have an increased risk of developing liver fibrosis.

One study found that in patients taking methotrexate, those who drank any amount of alcohol had a higher risk of liver fibrosis. Heavy alcohol consumption and obesity also raised the odds of methotrexate-induced liver damage.

Lowering Methotrexate Absorption

There is some evidence that alcohol can lower the absorption of methotrexate from the gastrointestinal tract. When less of the medication is absorbed into the bloodstream, methotrexate blood levels may be reduced.

Lower methotrexate levels could make the drug less effective for treating autoimmune disease symptoms. More research is still needed to confirm alcohol's effects on methotrexate absorption, but it's possible that alcohol may reduce the medication's efficacy.

Increasing Toxicity

Even if alcohol decreases methotrexate absorption, it can still increase the drug's toxic effects. Damaged liver cells are less able to clear methotrexate from the body effectively. When methotrexate builds up, it is more likely to cause adverse reactions.

Drinking alcohol while taking methotrexate essentially creates a perfect storm for liver toxicity. The liver has to process both the medication and alcohol, becoming overburdened and unable to clear methotrexate from the system efficiently.

Interfering With Methotrexate Metabolism

Methotrexate is converted into multiple metabolites as the body metabolizes the drug. Some studies indicate that alcohol metabolism may hinder this process. Having higher levels of methotrexate instead of its metabolites could increase the risk of toxicity.

Inhibiting Folate Absorption

Remember that methotrexate works by inhibiting folic acid metabolism. To counter this effect, methotrexate patients take folic acid supplements. However, alcohol can damage folate absorption in the intestines and increase the risk of folate deficiency.

Folate deficiency enhances methotrexate toxicity. When folate levels are low, methotrexate's side effects are amplified. Drinking alcohol can indirectly make methotrexate more dangerous by reducing folate levels.

Methotrexate and Bone Health

Many rheumatoid arthritis patients struggle with osteoporosis and have an increased fracture risk. Methotrexate may worsen bone loss, especially at high dosages. Alcohol can also inhibit optimal bone health.

The mechanisms linking methotrexate to osteoporosis are not fully understood. Possible factors include:

• Interference with osteoblast function
• Inhibition of bone cell growth
• Indirect vitamin deficiency effects

Alcohol impacts bone formation and breakdown, resulting in weaker bones. Binge drinking may be particularly detrimental for bone mass. Combining methotrexate and alcohol could have additive negative effects on bones.

Increased Risk of Fractures

Multiple studies have found that methotrexate is associated with an increased risk of fractures, especially at dosages of 15 mg per week or higher. Vertebral fractures and hip fractures may occur with greater frequency.

Alcohol consumption can also raise the odds of fractures. The combination of alcohol plus methotrexate could be especially concerning in terms of skeletal health.

Vitamin Deficiencies

As mentioned earlier, methotrexate impairs folic acid metabolism. Folic acid and other B vitamins like B12 are important for bone health. Deficiencies in these vitamins can contribute to weaker bones.

Heavy alcohol use often results in vitamin deficiencies that negatively impact bone density. The vitamin depletion caused by methotrexate and alcohol may be compounded, further increasing fracture risk.

Raising Fall Risk

Impaired balance and coordination due to alcohol intoxication increases the chances of falls. Methotrexate can also cause dizziness, fatigue, and weakness that make falls more likely. The sedative effects of alcohol combined with methotrexate side effects dramatically raise fall risk.

Falls result in about 95% of hip fractures. Reducing fall risk through exercise, home safety modifications, and avoiding alcohol can help protect those taking methotrexate.

Guidelines for Alcohol Consumption with Methotrexate

Given the serious health risks, consuming alcohol while taking methotrexate is generally discouraged. However, many rheumatologists say a small amount of alcohol may be safe for some patients.

Abstinence Ideal for Many Patients

For methotrexate patients who already have liver issues or are at high risk for toxicity, abstinence from alcohol is strongly recommended. People over 60, those taking diabetes or anti-seizure meds, and obese patients have greater susceptibility to liver damage.

Patients with a history of alcohol abuse or dependence should avoid drinking altogether when on methotrexate. Those with high RA disease activity and advanced joint damage may need to eliminate alcohol entirely too.

Low Level Drinking May Be Tolerated

For patients who are closely monitored and have shown no liver problems, limited alcohol consumption may be tolerated. Men are often advised to drink no more than 1-2 alcoholic beverages per day. Women are sometimes told to limit intake to just 1 drink daily due to body composition differences.

Patients should have liver function tested regularly, like once a month, when allowing any alcohol intake with methotrexate. Levels may need to be checked more often if drinking increases.

Avoid Binge Drinking

While a small amount of alcohol may be permissible for some patients, binge drinking should always be avoided. Consuming 4-5 or more drinks per occasion drastically raises the risk of liver toxicity and serious health consequences.

Time Alcohol Intake Carefully

Alcohol metabolism peaks 1-2 hours after intake. Taking methotrexate at the same time as drinking concentrates the burden on the liver. It is advisable to separate methotrexate dosage and alcohol consumption by several hours.

Some doctors recommend drinking only after methotrexate has cleared from the body, which takes 12-24 hours. However, timing the two precisely is difficult, so caution is still warranted.

The Bottom Line

Methotrexate and alcohol both place strain on the liver and can reduce bone density. Combining the two has a synergistic effect that makes liver toxicity, osteoporosis, and fractures more likely. Patients on methotrexate are usually advised to avoid alcohol entirely or limit intake to 1-2 drinks per day maximum.

Those who do choose to drink should have liver enzymes monitored closely for any sign of damage. Alcohol consumption should be avoided entirely by methotrexate patients with obesity, diabetes, liver issues, or a history of alcohol disorders. While limited alcohol may be tolerated by some, abstinence is the safest approach.

Disclaimer: This article is for informational purposes only and does not constitute medical advice. Always consult with a healthcare professional before starting any new treatment regimen.