title: Rheumatoid arthritis, alcohol, leflunomide and methotrexate. Can changes to the BSR guidelines for leflunomide and methotrexate on alcohol consumption be justified?
abstract: BACKGROUND
  The summary of product characteristics for leflunomide and methotrexate recommend avoiding alcohol. By contrast, the latest British Society for Rheumatology (BSR) guidelines suggest that alcohol should be 'well within national limits'. A postal survey was performed of rheumatoid arthritis (RA) patients to address their alcohol consumption, and assess whether this influenced any rise in alanine transaminase (ALT) levels while on leflunomide or methotrexate.
  
  
  METHODS
  RA patients commenced on methotrexate or leflunomide within the preceding two years were identified using the departmental database. A total of 200 patients on methotrexate or leflunomide were sent questionnaires covering demographics, disease details, duration of disease-modifying anti-rheumatic drug (DMARD) use, previous medical and drug history, alcohol advice recalled, and alcohol consumption while on the drug. ALT levels at drug commencement and the highest level on the drug were recorded.
  
  
  RESULTS
  Replies were received from 69.5% of methotrexate and 57.5% of leflunomide patients. 68.6% of patients recalled receiving alcohol advice. 55.8% of leflunomide patients did not drink alcohol prior to taking the DMARD, compared with 39.4% of methotrexate patients. 27.7% of leflunomide patients continued to drink alcohol compared with 64.3% on methotrexate. For both drugs, no patterns emerged to suggest that baseline or highest ALT levels were influenced by higher levels of alcohol consumption.
  
  
  CONCLUSIONS
  No differences were found with either methotrexate or leflunomide for self-reported alcohol consumption influencing ALT levels. It is appropriate to give similar alcohol advice to patients beginning therapy with either methotrexate or leflunomide. This research has not found any evidence to contradict the relaxation of advice on alcohol consumption with methotrexate and leflunomide in the updated BSR guidelines.
authors.affiliation: Department of Rheumatology, Derbyshire Royal Infirmary, Derby, UK.
authors.forename: Shyra
authors.initials: S
authors.lastname: Rajakulendran
authors.forename: Kate
authors.initials: K
authors.lastname: Gadsby
authors.forename: Chris
authors.initials: C
authors.lastname: Deighton
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000410:Alanine Transaminase / Q000097:blood; D000428:Alcohol Drinking; D018501:Antirheumatic Agents / Q000627:therapeutic use*; D001172:Arthritis, Rheumatoid / Q000188:drug therapy*; D002492:Central Nervous System Depressants; D000075202:Contraindications; D016208:Databases, Factual; D000431:Ethanol; D005260:Female; D019538:Health Care Surveys; D006801:Humans; D007555:Isoxazoles / Q000627:therapeutic use*; D000077339:Leflunomide; D008297:Male; D008727:Methotrexate / Q000627:therapeutic use*; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D011795:Surveys and Questionnaires
chemical_list: D018501:Antirheumatic Agents; D002492:Central Nervous System Depressants; D007555:Isoxazoles; D000431:Ethanol; D000410:Alanine Transaminase; D000077339:Leflunomide; D008727:Methotrexate