RA, Smoking, and Alcohol

The potential risks smoking and drinking pose to people with rheumatoid arthritis.


You already know that smoking is bad for you and that it's unhealthy to drink too much alcohol.

But do you know how tobacco and alcohol relate to rheumatoid arthritis -- your odds of developing RA, or, if you already have RA, your odds of making it worse?

Here's what the research shows.

 

RA, Smoking, and Your Genes

Smoking may make people more likely to get RA. And, depending on their genes, it may make their RA worse. On top of that, smoking mixed with RA can lead to even greater problems, like heart disease.

“Very clear studies indicate that tobacco is highly associated [with] and probably causal in rheumatoid arthritis and is causal in the worst form of the disease,” says Susan Goodman, MD, an assistant attending rheumatologist and internist at the Hospital for Special Surgery and assistant professor of medicine at Weill Cornell Medical College.

Your genes may also matter. A Swedish study, published in December 2010, shows that the odds of developing RA was related not just to how much a person smokes, but also to their genetic makeup. People with a certain gene variation, called HLA-DRB1, who smoke are much more likely to get rheumatoid arthritis than someone who doesn’t smoke -- and to have severe RA.

“It turns out that people who smoke who bear this genetic factor are much more likely to develop rheumatoid arthritis and do develop more severe disease," Goodman says.

Smoking can also make dealing with the disease more difficult.

“In a lot of the studies on the course of rheumatoid arthritis, patients who smoke do less well, and they’re less likely to achieve remission,” Goodman says. “They’re more likely to have a worse outcome. Smoking gives them a worse prognosis.”

Smoking can increase painful rheumatoid nodules, which form in the joints, she says. It can also lead to heart disease, which -- even on its own -- is a big problem in people with RA. And smoking makes it worse.

“In the last 10 years, there have been studies that show the leading cause of death in patients with RA is cardiovascular disease,” says Walter Moore, MD, senior associate dean for graduate medical education and veteran affairs at Georgia Health Sciences University and chief of rheumatology at Charlie Norwood Department of Veterans Affairs Medical Center. “And smoking itself is clearly associated as a risk factor for cardiovascular disease.”

Stroke is another concern for RA patients.

“RA is an illness like diabetes. In and of itself, it’s a risk factor for heart attack and stroke,” says Andrew Ruthberg, MD, an assistant professor of medicine and an attending physician at Rush University Medical Center and director of Rush Rheumatoid Arthritis Clinic. “And those two things conspire to raise your risk for those other problems to a higher level.”

The bottom line: Quit. But Goodman says she doesn't always address that first.

When patients come into her office for treatment, Goodman first focuses on getting their pain under control. After that, she then turns to their bad habits - like smoking.

“Certainly, everyone should quit smoking,” Goodman says. “And we try to help the patient do that.”

Ruthberg takes a harder stance.

“I don’t smoke myself,” he says, “and I don’t much like smoking. My father died of lung cancer, so it doesn’t take much for me to discourage anyone who smokes from smoking. But I usually talk about other health risks associated with smoking, like heart attacks and strokes.”

 

RA and Drinking

The lines between rheumatoid arthritis and drinking are blurrier. Alcohol doesn’t promote or help cause RA like smoking does. But mixing alcohol and medications can lead to liver problems.

Some studies have found that drinking in moderation may help lower the chance and the symptoms of rheumatoid arthritis. A study published online in Rheumatology in July 2010 found that drinking alcohol more than 10 days a month decreases “both risk and severity” of the disease. The study was based on information collected from patients about their drinking habits, which doesn’t prove drinking alcohol counters RA or its effects.

“We don’t spend very much time encouraging people to drink alcohol,” Moore says, “and all things being considered, we are using drugs that have hepatotoxicity (are toxic to the liver) as part of the patients’ regiments.”

The drug he’s talking about is methotrexate, a common RA medication. Mixing alcohol and RA medications like methotrexate, in particular, is risky. Plus, he says he’d like to see more information, like how much alcohol and what kinds -- whether liquor, beer, or wine -- helped people more before he’d suggest to his patients who have mild forms of RA that they might benefit from drinking alcohol.

Methotrexate, like other medications, is metabolized by the liver. And that’s where the dangers of drinking and medication mixing come into play.

When people drink alcohol, their livers work overtime to metabolize it. That’s why many people who drink heavily over a long period of time have liver damage.

Arava, which goes by the generic name leflunomide, is a companion drug to methotrexate. Moore says he won’t offer his patients either unless they agree to stop drinking completely or at least curtail their use of alcohol.

Some patients also use over-the-counter drugs such as acetaminophen (found in many pain relievers and other medications) to help control their pain. Medications such as these can also cause liver damage.

Physicians keep an eye on their patients’ liver functions through regular blood work that monitors liver enzymes. They can sometimes diagnose liver damage caused by both the medications and alcohol.

The bottom line: If you're wondering how much you can drink, talk to your doctor.

“Each rheumatologist is different about where they draw the line in the sand about how much they’ll let their patients drink,” Ruthberg says.

For his patients to stay on methotrexate, Ruthberg allows them no more than a few drinks per week.

Moore asks his patients to keep their drinking to a minimum. And drug interactions aren’t the only reason he suggests this.

Limiting alcohol, he says “is once again in respect to different things like obesity, alcohol issues, and accidents. For patients with RA, they may have problems with falling or less control with their hands. And alcohol may complicate that aspect of RA.

“For the type of practice that I have here at Georgia Heath Sciences University, we are really managing patients with more severe disease, more progressive disease. We’re in the fight of our lives to preserve their joints. To do anything to compromise these medicines, I would really be reluctant to do that.”

 

 

Stephanie Schupska - WebMD