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Rheumatoid arthritis and alcohol consumption

Managing alcohol intake can be important for those taking certain medications. Understanding the risks of drinking too much alcohol, sensible drinking levels and what a unit looks like can help you to manage your health.

Why are alcohol intake levels important in RA?

If you are being asked to reduce the amount of alcohol you drink, it can be beneficial to understand why that is and what the risks would be if you did not follow the recommendations on alcohol intake.

Certain RA medications, including methotrexate (the most commonly prescribed medication in RA) and leflunomide recommend limiting alcohol intake. These medications are broken down in the liver, and so is alcohol. Therefore when you drink alcohol, your liver needs to work harder to process both the alcohol you are drinking and the medication you are taking. This can put a strain on the organ, which can cause damage and stop your liver from working properly.

Non-steroidal anti-inflammatory drugs (NSAIDs, such as ibuprofen and diclofenac) can also be affected by alcohol intake. NSAIDs can affect the lining of the stomach, and alcohol can worsen this side effect. The NHS state that moderate alcohol consumption whilst taking NSAIDs will not usually cause any harm. However, the level of harm it causes could be affected by the dose of NSAID, how long you have been taking it and the amount of alcohol you consume, so it is still worth discussing this with your healthcare team.

Be honest with your team

Whatever your level of alcohol intake, it is important that you are honest with your healthcare team. If you drink at a level considered to be ‘heavy’ drinking (above UK government guidelines) you may need to reduce this, and you may benefit from support in doing so. If you continue to drink heavily and your healthcare team are not aware of this, it could affect their ability to safely prescribe and monitor medication for your RA. This can be the case for periodic or one-off heavy drinking as well. For example, if you celebrate a special occasion and drink more heavily than usual just before having a blood test to monitor liver function, the results may be abnormally high. If you do not inform your healthcare team that you were celebrating, they are likely to interpret the abnormal test results as due to your medication. This could lead to them asking you to temporarily or permanently stop taking a medication, potentially causing your RA to flare whilst other treatments are started. As well as flares of your disease, any new medication may bring with it other side effects.

Our helpline often get calls about alcohol consumption and RA and the majority are sheepish about bringing this up, concerned that it seems trivial or that people might think they have a problem with alcohol if they mention it. Please don’t think that you can’t speak openly to your healthcare team or to NRAS about this; they are here to help and won’t judge. For many, moderate drinking is an enjoyable and sociable lifestyle choice and there is nothing wrong with discussing this openly and frankly. Equally, if you think you might be drinking too heavily, you should not feel that you cannot raise this and ask about support that might help you.

Should I stop drinking altogether?

Your healthcare team is unlikely to ask you to stop drinking alcohol altogether if you do not wish to. In fact interestingly a number of studies have suggested that moderate alcohol intake can actually improve some RA symptoms. People who stopped drinking alcohol altogether have in some studies been found to have worse physical function and more pain and fatigue than moderate drinkers. It is important to note the word ‘moderate’ here, but it does suggest that there can be benefit to low levels of alcohol consumption. If you have psoriasis or psoriatic arthritis however, you may be advised to cut out alcohol altogether or reduce it more significantly, due to the increased impact of alcohol on both symptoms and treatment.

How much alcohol should I be drinking?

It is important to be guided by your own healthcare team, based on individual circumstances.

In RA, the majority of guidance on alcohol intake is based on those taking methotrexate. Whilst there is no strict guideline for healthcare professionals to follow on this, a number of trusted sources, including the British Society for Rheumatology (BSR) and National Patient Safety Agency (NPSA) recommend that alcohol intake for people taking methotrexate should be well within the guidelines set out nationally. For men and women, this should be no more than 14 units per week. Those units are better spread throughout the week over 3 or more days, rather than having them in one evening (often referred to as ‘binge drinking’). This is because a larger hit of alcohol in a short time period puts much more strain on your liver.

The following image, from ‘Drinkaware’ gives you a visual representation of what 1 unit of alcohol looks like, though it must be remembered that these are based on specific measures and strengths of alcohol, as shown in the picture.

A study in 2017 of over 11,000 RA patients taking methotrexate found that ‘weekly alcohol consumption of <14 units per week does not appear to be associated with an increased risk of transaminitis’ (a condition where too many liver enzymes are found to be present in the blood stream, picked up by a liver function test and indicating potential problems within the liver).

It is also important to note that sticking to <14 units per week, spread across at least 3 days would be recommended for anyone’s overall health, but for those taking medications such as methotrexate it is particularly important.

Top tips

Be honest: Give your healthcare team an accurate understanding of your level of drinking and let them know about one-off occurrences
Talk to your friends: Friends who you normally drink alcohol with may not understand the importance of limiting alcohol intake. It may help to explain this to them to avoid social pressure.
Use a unit calculator: Don’t assume that you know how many units are in ‘a glass of wine’. This will depend on the size of glass (if you are at home, you may want to buy a wine thimble measure) and the percentage of alcoholic content. You can download a unit calculator, or find one free online, such as the following: Alcohol Change unit calculator
Don’t binge drink: If you are sticking to a weekly maximum limit of units, these are better taken throughout the week, rather than all on one evening.

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