Question of the Week: Is moderate alcohol consumption OK if I’ve had pancreatitis in the past and still have elevated liver function tests?

The question this week comes from a person living with IgG4-RD who is in his 60s.

His journey has been classic: longstanding inflammation in the pancreas and bile ducts that remained undiagnosed for a substantial period, treated with steroids on and off – mostly on – for a while.

Ultimately the correct diagnosis of IgG4-related autoimmune pancreatitis (AIP) was made, and the patient was treated off-label with a B-cell depleting agent, rituximab. (“Off-label” means that the drug has not been approved for this disease by regulatory agencies such as the U.S. Food & Drug Administration, the European Medicines Agency, etc.).

Fortunately, the questioner has had an excellent response to B-cell depletion:

• Resolution of clinical symptoms

• Dramatic decline in serum IgG4 levels. The serum IgG4 remains elevated at approximately twice the upper limit of normal, but it is still declining slowly whenever the blood tests are assessed.

• Major improvement in “liver function tests”, specifically the aspartate aminotransferase [AST] and alanine aminotransferase [ALT], which are blood tests used to assess the status of problems involving the pancreas, bile ducts, and liver. These values have normalized.

The Question: Is it now permissible to have small to moderate amounts of alcohol – one drink of wine every other day?

The Answer: The IgG4ward! Foundation polled three leading key opinion leaders from the field of pancreatology in both Europe and the United States about the general question of moderate alcohol use in the setting of IgG4-related AIP that is in remission. All of the experts were asked separately.

Their responses, which are summarized below, are concordant:

• Moderate alcohol use that is truly moderate is probably fine.

• One glass of wine every other day qualifies as moderate in this setting and would be reasonable.

• Alcohol is alcohol. No specific beverage is better or worse. Beer has a lower alcohol concentration than wine, which has less than spirits.

• It is important to ensure that there is no active inflammation in the pancreas, bile ducts, or liver. The normal liver function tests are reassuring and should be monitored closely – every 3-4 months. The persistently elevated IgG4 concentration is likely OK as long as it is continuing to decline. It should therefore also be monitored closely.

• It is prudent to be extremely careful until the IgG4 has in fact normalized. This may take some months, even after remission is achieved.

• Imaging can be helpful in ensuring that there is no active inflammation. The studies to consider would be an MRCP (magnetic resonance cholangiopancreatography) or PET/CT (positron emission tomography/computed tomography).

There is an important caveat:

For people living with IgG4-related AIP who have evidence of exocrine pancreatic damage – namely, atrophy or calcification of the pancreas on imaging studies or a low level of elastase in a stool measurement – regular alcohol should be avoided. This means, for example, limiting alcohol consumption to one drink every once in a while, on a special occasion.

Stay up to date with the IgG4ward! Question of the Week by joining the IgG4ward! Online Community.