Can you drink ethanol (ETOH) while taking methotrexate?

Alcohol Consumption While Taking Methotrexate

Patients taking methotrexate should avoid alcohol consumption or limit it to well below national guidelines due to increased risk of hepatotoxicity. 1

Risk of Hepatotoxicity

• Alcohol consumption is a significant risk factor for methotrexate-induced hepatotoxicity, which is more common in patients with psoriasis than in those with rheumatoid arthritis 1
• Greater than moderate alcohol intake is specifically listed as a risk factor for hematologic toxicity and hepatotoxicity in patients taking methotrexate 1
• Methotrexate and alcohol both independently cause liver damage, and their combined effect increases the risk of liver fibrosis and cirrhosis 2

Guidelines for Alcohol Consumption

• The American Academy of Dermatology and National Psoriasis Foundation define moderate alcohol use that is considered harmful as:

  • For women: >1 alcoholic drink per day or >7 drink equivalents per week 1
  • For men: >2 alcoholic drinks per day or >14 drink equivalents per week 1
  • One drink equivalent = 1 shot of liquor = 12 oz beer = 5-6 oz wine 1

• The British Association of Dermatologists recommends limiting alcohol intake to "well below the national guidelines" while taking methotrexate 1

Research Evidence on Alcohol Consumption

• A 2017 study found that consuming <14 units of alcohol per week was not associated with increased risk of transaminitis in rheumatoid arthritis patients on methotrexate 3
• However, the same study showed that consuming >21 units per week significantly increased rates of liver enzyme elevation with an adjusted hazard ratio of 1.85 3
• Patients with psoriasis may be inherently more susceptible to methotrexate hepatotoxicity than those with rheumatoid arthritis, suggesting even greater caution with alcohol in these patients 4

Monitoring Requirements

• Regular laboratory monitoring is essential for patients taking methotrexate, especially those who consume any alcohol:
  • Complete blood count and liver function tests should be performed every 3-6 months assuming no abnormalities 1
  • More frequent monitoring is recommended after dose increases 1
  • Persistent elevations in liver enzymes should prompt consideration of dose reduction or discontinuation 1

Practical Recommendations

• Excessive alcohol intake is listed as a relative contraindication to methotrexate treatment 1
• Alcoholism is considered an absolute contraindication to methotrexate therapy 1
• If a patient has a history of significant alcohol consumption before starting methotrexate, they may be at higher risk for hepatotoxicity even if they reduce their intake during treatment 1
• For patients who cannot abstain from alcohol completely, consumption should be kept well below the moderate levels defined above 1

Special Considerations

• Patients with other risk factors for hepatotoxicity (obesity, diabetes, hyperlipidemia, chronic liver disease) should be even more cautious about alcohol consumption while on methotrexate 1
• The risk of hepatotoxicity increases with cumulative methotrexate dose, so long-term users should be particularly careful about alcohol consumption 1

In conclusion, while small amounts of alcohol may be tolerated by some patients on methotrexate, the safest approach is to avoid alcohol entirely due to the increased risk of hepatotoxicity and other adverse effects.