If you’re being treated for rheumatoid arthritis (RA) and want to enjoy a glass of wine — or two — how can you determine if that’s a safe, smart move? The answer: Unfortunately, it’s complicated.
The most recent Dietary Guidelines for Americans generally encourage not drinking at all or drinking in moderation, which means no more than two drinks a day for men and one drink a day for women. One drink is 5 ounces (oz) of wine, 12 oz of beer, or 1.5 oz of distilled spirits.
Per the guidelines, it’s safest to avoid alcohol altogether if you’re living with a medical condition that alcohol can worsen or if you’re taking medications that interact with booze — and some common RA medications do.
Liver function is a concern associated with the long-term use of a number of RA medications. Drinking alcohol while taking these medications can make it difficult for your physician to assess adverse reactions to your RA drug versus an adverse reaction to alcohol that may be causing an increase in liver enzymes. Your doctor may not be able to determine if it’s the RA drug or the alcohol that’s causing the increase. Even if you don’t drink, your doctor may have you stop your RA medication if your liver enzyme numbers increase, to prevent potential damage to your liver.
Does alcohol consumption worsen rheumatoid arthritis itself, or does it actually have a protective effect? The evidence isn’t entirely clear.
Research that looks at the effect of alcohol on autoimmune diseases, including RA, has found that low to moderate consumption seems mostly to have a protective role in these diseases, while at higher intake, the collateral risks outweigh any possible benefits.
Researchers don’t fully understand the specific mechanisms by which low to moderate alcohol intake (as opposed to heavy intake) alleviates symptoms of autoimmune diseases, but it may have a systemic immunomodulatory effect and beneficially influence the gut microbiome.
It appears that sex plays a role in how alcohol consumption impacts RA, possibly due to the effect of alcohol on estrogen. While various studies show that low to moderate alcohol consumption in women prevents the onset of RA, other research has found that increased alcohol consumption was associated with an elevated risk of RA among women, but not in men, and that moderate alcohol consumption increased the progression of RA in women, but not in men.
Yet another study found that people with RA tend not to drink when they don’t feel good, so when they do drink, it’s when their symptoms are already under better control. When adjusting for other factors, these researchers concluded that the use and changes in use of alcohol were not associated with disease activity or mortality, suggesting that alcohol consumptions does not have a clear benefit for RA.
What’s certain, however, is that many of the drugs used to treat RA can cause liver problems when combined with alcohol. Depending on your RA treatment and your health otherwise, the downsides of drinking can start to outweigh any potential benefits.
The main concern about alcohol and RA is damage to the liver. Both methotrexate (Trexall, Rheumatrex) — a disease-modifying antirheumatic drug (DMARD) commonly prescribed to manage RA symptoms — and alcohol can be taxing to this vital organ, and combining the two may compound the problem.
A study found that the risk of elevated liver enzymes in RA patients taking methotrexate was greater with higher alcohol consumption, and researchers tried to determine whether there was an acceptable level of alcohol consumption for those taking that drug. Over the course of three decades, researchers studied nearly 12,000 RA patients who take methotrexate and found that those who consumed fewer than 14 units of alcohol (about 7 drinks) a week while taking the DMARD had no increased risk of liver damage compared with those who didn’t drink. But those who consumed more than that were at higher risk of developing serious liver problems.
Can you drink alcohol if you’re taking methotrexate, and if so how much? The American College of Rheumatology advises that alcohol should be avoided in this case. Prescribing information for methotrexate notes that the risk of liver toxicity is increased with “heavy alcohol consumption” and recommends telling your healthcare provider if you drink alcohol.
Most rheumatologists recommend avoiding alcohol altogether if you’re taking methotrexate.
Pain relievers, including nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil, Motrin) and naproxen (Aleve), also don’t mix well with alcohol. They’re more likely to cause gastrointestinal bleeding when alcohol is consumed. Drinking while taking acetaminophen (Tylenol) leaves you more vulnerable to liver trouble, too.
TNF-inhibitors — biologic medications that include adalimumab (Humira), etanercept (Enbrel), and infliximab (Remicade) — don’t come with warnings and precautions related to alcohol, but they do now come with labeling about possible liver injury, per the U.S. Food and Drug Administration (FDA).
Another class of drugs called Janus kinase inhibitors (JAK inhibitors), which includes tofacitinib (Xeljanz), baricitinib (Olumiant), and upadacitinib (Rinvoq), also don’t specifically warn against interactions with alcohol. But JAK inhibitors have been associated with cases of liver enzyme abnormalities. And they’re often prescribed along with methotrexate, meaning it’s still important to use caution and limit alcohol intake to avoid liver damage.
Other drugs used to treat RA, such as azathioprine, leflunomide, and sulfasalazine, can also potentially result in liver toxicity.
Liver function isn’t the only concern. Research has found that people who consumed 1–2 drinks per day had a 1.34 times higher risk of osteoporosis than people who didn’t drink at all. People who consumed two drinks or more per day had 1.63 times the risk of developing osteoporosis. This is important for people with RA who are already at a greater risk of osteoporosis and who may be dealing with bone loss and joint pain.
If you have rheumatoid arthritis and are considering drinking alcohol, it's crucial to discuss this with your healthcare provider, especially if you're on medications like methotrexate, as alcohol can increase the risk of liver damage.
The relationship between alcohol and autoimmune diseases like RA is complex, and while low to moderate alcohol consumption might have some protective effects, high intake poses significant health risks, including exacerbated liver issues.
Nonsteroidal anti-inflammatory drugs (NSAIDs) frequently used in managing RA can cause stomach bleeding when combined with alcohol.
Alcohol consumption may increase your risk of osteoporosis, which is already elevated in people with RA.
Have an open, honest conversation with your doctor to see if drinking in moderation or on occasion is okay for you. There are a number of other factors to consider beyond your RA treatment regimen — and every individual is different.
