Q J Med 2000; 93:35–40
Low-dose ethanol consumption allows strength recovery in chronic alcoholic myopathy J. FERNA´ NDEZ-SOLA` , J.M. NICOLA´ S, E. SACANELLA, J. ROBERT, M. COFAN, R. ESTRUCH and A. URBANO-MA´ RQUEZ From the Department of Internal Medicine, Institut d ’Investigacions Biome`diques August Pi i Sunyer, Hospital Clı´nic, University of Barcelona, Spain Received 16 July 1999 and in revised form 21 September 1999
Summary Chronic skeletal myopathy may affect one third of chronic alcohol misusers. It is generally accepted that abstinence allows partial recovery, and that continued high-dose ethanol consumption progressively deteriorates muscle function. However, the effect of low-dose ethanol consumption in alcoholic myopathy has not been studied. We studied 58 chronic alcoholic male patients with biopsy-proven chronic alcoholic myopathy over 5 years. We evaluated ethanol intake, biochemical and nutritional parameters, and assessed muscle strength. Eighteen patients who remained abstinent showed marked
improvement in muscle strength. As expected, the 19 patients who persisted in high-dose ethanol consumption further diminished in their muscle strength. In the 11 patients who maintained lowdose (∏60 g ethanol/day) ‘controlled’ drinking, muscle strength improved ( p=0.003), despite no change in nutritional and exercise status. There is a dose-dependent recovery in muscle strength according to the degree of ethanol consumption, and moderate controlled drinking of up to 60 g ethanol/day still allows improvement in muscle strength.
Introduction
chronic alcoholics with skeletal myopathy, to evaluate the effects of different doses of ethanol on muscle function. Muscle strength, measured by myometry, was taken as the paradigm of skeletal muscle function.5,6,10
About one third of long-term high-dose alcohol misusers develop skeletal myopathy, which appears in a dose-dependent manner, and manifests clinically as proximal muscle weakness, pain and atrophy.1–6 Once established, alcoholic myopathy usually reverses provided complete abstinence is achieved.7–9 By contrast, continued high-dose alcohol abuse is accompanied by further deterioration in muscle strength and the appearance of histological damage to the muscle.10 In the treatment of alcoholic patients, the first goal is to achieve complete abstinence from ethanol intake. However, abstinence is not always possible, and a significant percentage of alcoholics are only able to reduce their intake to ∏60 g of ethanol a day (‘controlled’ drinking).11 Since little is known about the consequences of ‘controlled’ drinking on the natural history of chronic skeletal myopathy,7,10 we studied a large series of
Methods Patient selection and baseline studies Over a 2-year period, we consecutively selected male patients seen in the Alcohol Unit of the Hospital Clı´nic of Barcelona. This unit treats only ambulatory patients who seek assistance in terminating their dependence of alcohol, but who have no signs or symptoms of other diseases. Patients with other maladies, or overt alcohol-related disorders such as liver cirrhosis, heart failure or malnutrition, are referred to other clinics. Patients with HIV infection, neoplasm, consumption of illicit drugs or with causes
Address correspondence to Dr J. Ferna´ndez-Sola`, Department of Internal Medicine, Hospital Clı´nic, Villarroel 170, 08036 Barcelona, Spain. e-mail:
[email protected] © Association of Physicians 2000
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J. Fernandez-Sola et al.
of myopathy other than alcoholism were not selected for the study. Patients who complained of muscle weakness or myalgia, or those with a significant reduction in muscle strength (1 h/day.
Follow-up studies As a result of the detoxification program, 18 patients became abstinent and maintained sobriety over the 5 years, whereas 40 continued drinking. Of the latter, 11 patients (28%) reported a daily ethanol consumption of 20–60 g (‘controlled’ drinking), 10 (25%) drank 61–99 g ethanol/day, and 19 (47%) maintained an ethanol consumption of at least 100 g/day. Nevertheless, in heavy drinkers (100 g ethanol/day), alcohol consumption fell from 227±16 g/day at baseline to 143±12 g/day in the follow-up period (Table 2). Throughout the followup period, patients did not exhibit changes in biochemical and nutritional parameters except for significant improvement in the tricipital skin fold, albumin, gammaglutamyl transpeptidase and aminotransferases (Table 1), which occurred in all groups except those who maintained an ethanol intake of 100 g/day (Table 2). The degree of histological
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myopathy at baseline was similar in all groups (Table 2). Figure 1 depicts the differential evolution of muscle strength according to the degree of ethanol consumption over the 5-year follow-up period. Abstinent patients (n=18) showed a significant improvement in mean muscle strength from 18.0±1.2 to 24.4±0.7 kg ( p100 g/day) caused further deleterious consequences in muscle strength. Moreover, in the group of patients who continued drinking 61–99 g ethanol/day there was no significant change in muscle strength. We considered this group as marginal or indeterminate, since half of these patients improved and half of them deteriorated during the study. This may reflect individual biological variability, the fact that alcohol consumption reports are estimates, or the lack of a sharp distinction between excessive and controlled drinking.
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Table 2 Characteristics of 58 alcoholic patients with skeletal myopathy according to their degree of ethanol consumption during 5 years follow-up Daily ethanol intake
100 g (n=19)
20–60 g (n=11)
Baseline
5 years
Baseline
5 years
Baseline
5 years
18.0±1.2 203±14 96.8±1.8 47.4±1.0 7.5±0.5 71.2±1.6 40.6±1.2 49.1±8.6 114±27 110±21 1.1±0.3 14/3/1
24.4±0.7 NA 101±1.5* 50.6±1.4* 9.6±0.8* 71.3±1.6 46.0±1.6* 24.5±3.1** 26.1±3.0** 112±12 1.4±0.5 NA
18.5±1.2 179±17 96.5±1.7 47.0±1.2 10.0±0.8 71.1±1.1 43.6±3.7 48.8±18.3 124±25 153±45 1.2±0.4 7/3/1
22.3±1.4 41±4*** 97.1±1.6 48.7±1.5 11.6±1.2 72.6±2.1 46.5±1.6 40.0±8.5 33.2±12.4* 122±14 1.3±0.3 NA
21.8±1.1 227±16 99.5±1.8 48.1±1.2 8.5±1.3 70.7±4.4 41.0±3.1 92.6±47.0 156±90 73±13 1.2±0.5 15/4/0
18.0±1.1 143±12*** 98.4±2.1 48.1±1.8 8.2±1.1 69.5±2.0 38.9±4.2 25.3±3.4* 51.6±30.8* 89±16 1.3±0.4 NA
† Number of patients in each group corresponding to mild/moderate/severe histological myopathy.5 NA, not applicable. * p
