Can I drink any alcohol while taking methotrexate?

There is no single safe amount of alcohol that applies to everyone taking methotrexate. Complete avoidance is the most conservative and safest choice. However, some clinicians may allow a strictly limited amount (such as 1 to 2 standard drinks per month) for selected patients who have no underlying health risks. You should never assume it is safe to drink on a special occasion without first discussing your usual and planned alcohol intake with your prescriber.

Note: This page discusses low-dose weekly methotrexate used for conditions like rheumatoid arthritis or psoriasis. Methotrexate for these conditions is taken weekly, not daily. Taking it daily by mistake is a medical emergency. If you are receiving high-dose oncology regimens for cancer, you must follow your oncology team’s specific protocol, which will likely be much stricter.

The Risk to Your Liver

Both methotrexate and alcohol can separately contribute to liver injury. Methotrexate alone can sometimes cause elevated liver enzymes, which are markers in your blood that indicate liver stress or cellular inflammation ^[1]. Combining alcohol with methotrexate increases the risk of acute (sudden) liver injury ^[2].

Over time, there is also a risk of developing liver fibrosis, which is the thickening and scarring of liver tissue. While cumulative exposure to methotrexate over many years plays a role, modern risk assessment emphasizes that metabolic risk factors—such as obesity, diabetes, older age, abnormal liver tests, and existing liver conditions—are heavily associated with developing fibrosis ^[3]. Adding alcohol to this mix, especially heavy or binge drinking, significantly increases this risk.

Additionally, methotrexate is predominantly cleared from your body through your kidneys, not your liver ^[4]. If you have reduced kidney function, the medication stays in your system longer, increasing the likelihood of adverse reactions and toxicity ^[4].

What Standard Guidelines Recommend

Standard treatment guidelines, such as those from the American College of Rheumatology (ACR), have historically guided practitioners to recommend strict limits on alcohol or complete avoidance, though specific rules vary by country and medical specialty ^[5].

Your prescribing doctor or pharmacist will set a limit for you based on a pretreatment assessment of your individual risk factors:

• Factors generally requiring strict avoidance: Heavy or binge drinking, a history of liver disease (like viral hepatitis), reduced kidney function ^[4], already elevated liver enzymes ^[1], or taking other interacting medicines.
• Factors requiring careful discussion: Obesity, diabetes, or metabolic-associated fatty liver disease, which can increase the odds of drug-induced liver injury ^[6].

(Note: If you currently drink heavily on a daily basis, do not stop abruptly without medical supervision, as sudden cessation can cause dangerous alcohol withdrawal).

Monitoring and When to Seek Help

Because liver injury often happens without you feeling sick, you will be required to undergo scheduled blood tests to check your liver enzymes (like AST and ALT), bilirubin, blood counts, and kidney function ^[2][7]. If your tests show elevated enzymes, it does not automatically mean you have irreversible damage. Your doctor will interpret the pattern and may repeat the tests, adjust your dose, or briefly pause the medication. Normal blood tests, however, do not guarantee that drinking alcohol is entirely safe.

When to Seek Urgent Advice
Do not wait for your next routine blood test if you suspect toxicity. Contact your prescriber, urgent care, or poison-control service promptly if you:

• Accidentally take an extra dose or take methotrexate daily
• Develop visible symptoms of methotrexate toxicity, such as mouth ulcers, painful swallowing, severe nausea or persistent vomiting, unusual bruising or bleeding, marked fatigue, or a new rash with facial swelling ^[8][9][10]
• Notice yellowing of your skin or eyes, dark urine, or pale stools

If you have already had a drink or accidentally taken an extra dose, do not independently skip, double, or change your next weekly dose. Call your prescriber for individualized instructions on how to proceed safely.