As if learning you’ve been diagnosed with inflammatory arthritis wasn’t enough of an adjustment, finding out that you need to cut out alcoholic beverages while you take methotrexate, a commonly prescribed disease-modifying drug, can also be a bit of an aftershock.

Diseases like psoriatic arthritis and rheumatoid arthritis are lifelong — does this mean after-work wine or a cocktail during your Saturday night dinner plans is off the table?

For its part, the American College of Rheumatology says “methotrexate should not be taken if kidney or liver function is not normal. Alcohol significantly increases the risk for liver damage while taking methotrexate, so alcohol should be avoided.”

But how this plays out for individual patients can vary based on your own risk factors, as well as your doctor’s judgment.

For example, according to a RheumNow survey of nearly 500 rheumatologists (both U.S. and non-U.S.), about half of those surveyed will allow one to three alcoholic drinks a week for patients on MTX. A quarter allow only one to three drinks per month; 15 to 20 percent don’t advise no alcohol use. Six to 7 percent don’t restrict patients’ alcohol intake, as long as there is no underlying liver disease.

Here’s what you need to know about alcohol consumption while taking methotrexate.

1. What Is Methotrexate?

Methotrexate is one of the most effective and commonly used medications in the treatment of rheumatoid arthritis and other forms of inflammatory arthritis, says the American College of Rheumatology. It can be used by itself or with other medications. Here are the most common questions patients have about taking methotrexate.

Methotrexate is considered a traditional DMARD, or disease-modifying anti-rheumatic drug, because it not only reduces arthritis pain and swelling, but it can also prevent damage to joints and long-term disability. You can take methotrexate in pill form or by injection, usually as a single dose once a week.

2. Why Should You Avoid Alcohol While Taking Methotrexate?

Both alcohol and methotrexate affect your liver, so the two of them combined increases the potential for liver damage, says rheumatologist Vinicius Domingues, MD, CreakyJoints medical advisor.

While methotrexate is generally well tolerated, it has been associated with a range of liver-related adverse events, ranging from benign elevations in blood tests to fibrosis (the formation of scar tissue) and, in rare cases, and fatal hepatic necrosis, which is an acute toxic injury to the liver.

Arthritis patients who already have an increased risk of liver damage are more susceptible to further damage from drinking alcohol while on methotrexate than people with otherwise healthy livers. This could include those with different forms of hepatitis (A, B, or C), who have struggled with alcohol use disorder, cirrhosis, hemochromatosis, and fatty liver disease (which more commonly affects obese patients).

The type of arthritis you have may also be a factor in how methotrexate — and alcohol intake — affects the liver. “Methotrexate-treated psoriatic arthritis patients have a higher incidence of liver toxicity compared with methotrexate-treated patients with rheumatoid arthritis,” says Dr. Domingues, though “it is not really clear way that would be the case.”

3. What About Avoiding Alcohol If You Have Inflammatory Arthritis, Even If You Don’t Take Methotrexate?

It’s a good idea to watch your alcohol intake for other reasons too. For one thing, there are other drugs used to treat arthritis that can potentially cause liver damage, such as azathioprine, leflunomide, sulfasalazine, and certain biologic agents.

Another factor to consider is that alcohol can also lower bone density, and people with rheumatoid arthritis and psoriatic arthritis are already at a higher risk of developing osteoporosis. Excess alcohol intake can disrupt the breakdown and rebuilding of bone tissue.

So, if I need to take methotrexate, can I never imbibe again?

Whether to drink, or how much to drink, calls for a discussion with your doctor about the risks and benefits.

One headline-generating study from 2017 found that the risk of liver damage in people with RA who consumed fewer than 14 units of alcohol a week was no greater than that of people who didn’t drink alcohol. (Note: A unit does *not* equal a drink. According to this site, a unit is equivalent to 2.5 ounces of wine, 8 ounces of beer, or 0.8 ounces of whiskey.)

“Even though the study states that weekly alcohol consumption of less than 14 units per week does not appear to be associated with an increased risk of liver damage, no alcohol is always better than some alcohol,” says Dr. Domingues. “Each patient is different from the other and I would always rather be in the safer side when it comes to advising them. It’s always about a negotiation with the patient.”

Rheumatologist Jack Cush, MD, executive editor of RheumNow, wrote in an article on this site that he doesn’t allow drinking alcohol for people with psoriasis, psoriatic arthritis, or who have hepatitis B or C. For RA patients, he supports rare or social alcohol use, noting that it should not be consumed every day of the week.

He too reminds all patients that “no alcohol is always safer than some alcohol” though he says “ I believe the same can be said for milkshakes.”

For patients who are accustomed to a high alcohol intake, Dr. Domingues encourages them to gradually decrease before they start taking methotrexate. The less alcohol you can drink, he says, the better.

For stable patients without liver damage, which your doctor will screen for through ongoing blood tests, Dr. Domingues says he does permit patients to drink alcohol on special occasions if they choose.

“Not being flexible does not help anyone and could decrease medication adherence,” he says.

If you and your doctor agree that it is OK to drink on occasion, ask if there’s anything else you should keep in mind about minimizing risks to your liver health. For example, some doctors suggest you avoid drinking on the day before and after you take methotrexate.

5. What About the Health Benefits of Drinking Alcohol?

Alcohol is known for certain anti-inflammatory and cardio-protective health benefits. For example, one 2014 study in the Journal of Rheumatology found that rheumatoid arthritis patients who drank a small amount of alcohol reported better functional status than those who abstained completely. But the key is moderation.

“If you currently don’t drink, don’t start drinking for possible health benefits,” says Dr. Domingues. “A balanced diet and regular exercise have more benefits than alcohol consumption. In some cases, it’s safest to avoid alcohol entirely — the possible benefits don’t outweigh the risks. It has to be evaluated case by case.”

A Final Word from CreakyJoints

Deciding whether consuming alcohol is safe while on treatment for inflammatory arthritis comes down to an open conversation between you and your doctor. “The key is the development of an honest doctor-patient relationship,” says Dr. Domingues. “Don’t feel intimidated discussing these topics.”

Your doctor needs to understand the importance of your social life, and can help you understand the risks of drinking alcohol based on your specific health history.

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