Beware of Those Beers

Taking a good social history from patients involves asking about alcohol consumption. Drinking has many wide-ranging health implications. But as a rheumatologist, my concerns regarding my patient’s drinking habits are fairly narrow. Alcohol consumption plays havoc with a gouty patient’s hyperuricemia. Alcohol also doesn’t mix well with many rheumatoid arthritis medications such as methotrexate or leflunomide.

Some of my patients just can’t imagine life without beers or booze. As far as I can recall, the only patients in this elite category are men. If there are women in my practice who have similar drinking habits, they have escaped my notice thus far and have flown under my clinical radar.

A few times a year, I have a conversation that goes something like this: I tell the patient that their RA is poorly controlled with their current medications. The implications of this are obvious, but I spell them out anyway: "If we don’t do more to control your arthritis, you will have worsening problems with pain, joint damage, and possibly disability. I could put you on more effective treatment, but you would have to stop drinking alcohol, or at the very least, cut way back on your drinking." A lot of these guys look at me as if I had asked them to do something completely impossible or unreasonable.

One afternoon in clinic, my curiosity got the better of me, and I asked one of my 12 beer a day guys how he allotted his daily beers. I had the naivete to ask him if he drank four beers with breakfast, four beers with lunch, and another four beers with dinner. He gave me a slightly offended look, and I knew I had put my foot in my mouth. With wounded dignity he explained that he only drank in the evenings! What could I have been thinking?

Class and health insurance figure heavily in these situations. Sometimes, my RA patients who won’t swear off their beloved six packs can bypass MTX and go directly to a biologic medication. Many insurance companies will deny coverage for these expensive wonder drugs if the patient hasn’t tried MTX first. Since MTX is much less expensive and quite helpful, I think the insurance company has a legitimate gripe if the doctor tries to bypass a trial of MTX.

One of my patients with a fancy job in state government was able to start a biologic after I told the insurance company that he had tried some other medications that didn’t work, and I felt that MTX was contraindicated for him! I guess if the insurance company asked me the reason I felt MTX was contraindicated, I could have written down ICD 9 code V69.8 (beer drinker). Unfortunately, health insurance is usually not so understanding and benevolent for my other patients in similar situations.

I have another patient with active RA who refuses to quit drinking. He is an unemployed school janitor with marginal insurance benefits and he won’t be able to start any expensive medications. I have told him bluntly on several occasions that his drinking made it impossible for me to effectively treat his arthritis, but we remain in a standoff.

My gouty patients generally don’t have such somber and dire situations. One young man that works in a store warehouse keeps popping up in my office with great frequency after his latest drinking binge caused a gout flare up. I keep reminding him that alcohol is bad for his gout, and he keeps giving me hang dog looks. I patch him up for a little while with prednisone, but he keeps popping back in. I’ve told a few patients that wine (in moderation) was not as bad for gout as whiskey or beer, but I have yet to see someone come back to the clinic and tell me that their gout improved once they switched to wine from beer or whiskey.

Another heavy drinking patient was referred to me because of large tophi. He was not making any progress with traditional uric acid–lowering drugs. I explained to him that if we could lower his uric acid sufficiently, then his tophi would slowly shrink away. I told him that he would need to take uric acid–lowering drugs, and he would need to help his own cause by consuming much less booze.

He had large ugly tophi on both hands that he felt were attracting notice and interfering with his ability to sell real estate. He also felt that drinking with clients was essential to keep business progressing smoothly. He didn’t like my incremental approach at all. He wanted swift action, and I recalled hearing about pegloticase at the 2010 American College of Rheumatology annual meeting. He loved the idea of having an expensive high-tech medication that would shrink his tophi rapidly. Money is never an object when the insurance company is paying the bill. I don’t know how many patients are receiving pegloticase for this indication, but I’m sure there aren’t any who are more enthusiastic about the drug. The last time I saw him in the office his tophi were dramatically smaller. I cautioned him that the medication was not a substitute for important lifestyle modifications, such as cutting back on alcohol, but I think he took this to be just more "yada-yada" from an insensitive doctor with a job to do.