Background/Purpose: Rheumatoid arthritis (RA) is associated with an increased risk of premature cardiovascular events and mortality. Prospective general population studies have shown moderate alcohol consumption is associated with a 25-40% reduced risk of all-cause mortality and coronary heart disease (CHD). Alcohol use has been discouraged in RA patients taking methotrexate (MTX) due to potential liver toxicity. However, a recent population-based study found moderate alcohol consumption (0-14 UK units or 0-8 US drinks per week) was not associated with a higher risk of hepatotoxicity. The aim of this study is to examine the effect of alcohol intake on all-cause mortality and CHD events among RA patients taking disease-modifying anti-rheumatic drugs (DMARDs), including those taking MTX.

Methods: A prospective cohort study (1995-2017) was conducted using electronic medical records from The Health Improvement Network (THIN) database, representative of the general United Kingdom (UK) population. Our study population consisted of RA patients taking MTX or other DMARDs. Alcohol exposure was defined as first recorded alcohol use following RA diagnosis and divided into 5 categories: non-drinkers, 1-7 units/week (mild), 8-14 units/week (moderate), 15-21 units/week (moderate-high) and >21 units/week (high), where 1 UK unit = 8g alcohol.  We created Cox-proportional hazard models using age as the time-scale and calculated hazard ratios (HR) for the relation of alcohol consumption to all-cause mortality and CHD events, adjusting for age, sex, body mass index (BMI), smoking status, and Townsend deprivation index.

Results: Of 43214 patients with RA (women: 70%, mean age: 60.2 years), 9102 deaths and 2013 CHD events occurred over 350612 person-years (mean follow-up = 8 years). Alcohol use was associated with a decreased risk of all-cause mortality in RA patients taking MTX, particularly with mild to moderate use. When the analysis was restricted to other DMARDs, the results did not change materially (Table). Alcohol consumption was also associated with a decreased risk of CHD events in both groups, most prominently with moderate-high to high use (Table). 

Conclusion: In this prospective cohort study, mild to moderate alcohol use is associated with decreased risk of all-cause mortality among RA patients taking MTX and patients taking other DMARDs. Alcohol consumption is also associated with a decreased risk of CHD events in both groups. Given these results, the prior recommendation for avoiding alcohol use in RA patients taking MTX warrants reconsideration.

Table. Relation of Alcohol Consumption to All-Cause Mortality and CHD Events in Patients with RA

†Units based on standard UK measures where 1 unit = 8g alcohol. By US standards, 4 drinks = 7 UK units

‡Adjusted for age, sex, BMI, smoking status, and Townsend deprivation index