Call a doctor immediately if you have rheumatoid arthritis and experience these symptoms
Doctors themselves, or with “call partners,” cover urgent medical concerns for their patients when the office is closed.
People with rheumatoid arthritis can develop certain symptoms that are really warning signs of something occurring in their bodies that is not what the doctor expects to happen. These are signs that can also sometimes represent a significant danger. These “rheumatoid warning signs” are reasons to call the doctor so that they can be interpreted in light of the patient’s overall condition. When the doctor who is aware of your condition hears of these symptoms, he/she can determine whether or not they are serious and if any action should be taken immediately or in the near future.
Rheumatoid warning signs can represent a worsening or complications of the rheumatoid disease, side effects of medications, or a new illness that is complicating the condition of patients with rheumatoid arthritis. Patients with rheumatoid arthritis should be aware of these rheumatoid warning signs so that they can contact their health care professional before their health is jeopardized.
Here are some warning signs that I like my patients to call me about.
Worsening of joint symptoms
This includes more pain, more swelling, additional joint involvement, redness, stiffness, or limitation of function. The doctor will determine whether or not these are significant, not the patient. Sometimes, patients have just begun a medication and some minor increase in joint problems might be occurring while the medication is taking effect. However, worsening symptoms can also mean that the medications are not working and that they require adjustments in dosing or a change in the medications.
Lack of improvement of joint symptoms
One major purpose of seeing the doctor is to get better. The doctor knows this. If a patient with rheumatoid arthritis has seen the doctor and is started on a treatment program and is not showing improvement but is worsening, notification of the doctor is appropriate. After starting a new treatment program, it sometimes takes time for the medications, physical therapy, etc., to control the inflammation. It is up to the doctor to decide if things are on course.
A mildly elevated temperature is not unusual in a person with active inflammation from rheumatoid arthritis. However, a true fever (temperature is above 100.4 F or 38 C) is not expected and can represent an infection. People with rheumatoid arthritis are at increased risk for infection because of their disease and frequently because of their medications. Many of the medications used to treat rheumatoid disease suppress the immune system of the body that is responsible for defending against infectious microbes. Furthermore, these medications can increase the risk of a more serious infection when a bacterium or virus strikes. It is important for people with rheumatoid arthritis to notify the doctor as soon as a fever occurs so that infections are treated at the earliest time possible. This can minimize the chances for many serious complications of infections.
Numbness or tingling
When a joint swells, it can pinch the nerves of sensation that pass next to it. If the swelling irritates the nerve, either because of the inflammation or simply because of pressure, the nerve can send sensations of pain, numbness, and/or tingling to the brain. This is called nerve entrapment. Nerve entrapment most frequently occurs at the wrist (carpal tunnel syndrome) and elbow (ulnar nerve entrapment). It is important to have nerve entrapment treated early for best results. A rare form of nerve disease in patients with rheumatoid arthritis that causes numbness and/or tingling is neuropathy. Neuropathy is nerve damage that in people with rheumatoid arthritis can result from inflammation of blood vessels (vasculitis). Vasculitis is not common, but it is very dangerous. Therefore, it is important to notify the doctor if numbness and/or tingling occurs.
Rashes can occur for many reasons in anybody. However, in people with rheumatoid arthritis, the medications or, rarely, the disease can cause rashes. Medications that commonly cause rashes as side effects include gold (Solganal, Myochrysine), methotrexate (Rheumatrex, Trexall), leflunomide (Arava), and hydroxychloroquine (Plaquenil). A rare, and serious, complication of rheumatoid arthritis is inflammation of blood vessels (vasculitis), which can cause rash that most commonly appears in the fingertips, toes, or legs.
Redness of the eyes can represent an infection of the eyes, which is more common in people with rheumatoid arthritis because of dryness of the eyes (Sjögren’s syndrome). Redness can also result from blood vessel inflammation (vasculitis), especially when pain is present.
Vision loss of red/green color distinction
A rare complication of the commonly used rheumatoid arthritis drug hydroxychloroquine (Plaquenil) is injury to the retina (the light-sensing portion of the back of the eye). The earliest sign of retinal changes from hydroxychloroquine is a decreased ability to distinguish between red and green colors. This occurs because the vision area of the retina that is first affected by the drug normally detects these colors. People who are taking hydroxychloroquine who lose red/green color distinction should stop the drug and contact their doctor.
Nausea is a common problem in patients with rheumatoid arthritis, usually because of the medications that are required to keep the joint inflammation minimized. Medications frequently used to treat rheumatoid arthritis that can cause nausea include nonsteroidal anti-inflammatory drugs (NSAIDs such as ibuprofen [Advil], naproxen [Aleve], and many others), prednisone and prednisolone, azathioprine (Imuran), and methotrexate (Rheumatrex, Trexall). Nausea is usually not serious, but it is always annoying. Depending on the particular situation, the doctor may have the options of stopping the drug, lowering the dose, and/or adding a medication to treat the nausea.
Vomiting can be caused by the same drugs that cause nausea. Obviously, it is also possible to have a new underlying condition that could cause vomiting. It is most important to notify the doctor about this symptom, not only because of what it could represent, but also because it can lead to dehydration. Dehydration is never good for patients taking arthritis medications as it can increase the chances for side effects of the drugs, such as kidney injury.
Diarrhea can also lead to dehydration. Diarrhea can be caused by arthritis medications, such as NSAIDs, oral gold, and leflunomide. Diarrhea is also a common side effect of misoprostol (Cytotec), a medication that is used to protect the stomach while taking NSAIDs. The doctor may discontinue the drug causing the problem, make a dosage adjustment, and/or add a medication to stop the diarrhea.
Constipation generally occurs in people with rheumatoid arthritis because of medications. While constipation can happen with almost any medication, it is most common with the narcotic pain medications, including hydrocodone (Vicodin), propoxyphene (Darvocet), and others. People taking these medications should stay well hydrated. If patients with rheumatoid arthritis notice new constipation, the doctor should be notified.
Dark-colored stools can be caused by bleeding from the stomach. Bleeding from the stomach can be caused by inflammation of the stomach lining (gastritis) or ulcers. Gastritis and stomach ulcers are side effects from aspirin or any other NSAID. People with dark stools should notify their doctor immediately.
Insomnia is a real hassle. It is not fun and also is not healthy for people with rheumatoid arthritis, who require good sleep as part of managing their inflammation. Insomnia can occur because painful joints keep people with rheumatoid arthritis awake. It can also be caused by medications, particularly cortisone medications such as prednisone (Orasone) and prednisolone. There are ways of managing insomnia, and the doctor should be notified if it becomes a regular problem.
Dizziness, lightheadedness, ringing in the ears
Dizziness, lightheadedness, or balance problems are dangerous. Common causes include medications, such as aspirin or other NSAIDs, and low red blood counts (anemia). Ringing in the ears (tinnitus) is a frequent side effect of aspirin and NSAIDs. The doctor must be notified should any of these symptoms be noticed.
Unusual headaches should be reported to the doctor for general purposes and because headache can be a side effect of medications. In particular, headaches can be caused by NSAIDs. Sometimes, the headaches are related to the dosage of the medicine. Lowering the dose can eliminate the headaches while still providing a beneficial effect. All medication changes should be guided by the doctor.
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People with rheumatoid arthritis are at increased risk for infection. This risk occurs because the rheumatoid disease is an immune-suppressed condition and because many of the medications that are used to treat rheumatoid arthritis can suppress the immune system. Examples of rheumatoid medications that suppress the immune system are methotrexate (Rheumatrex, Trexall), azathioprine (Imuran), infliximab (Remicade), etanercept (Enbrel), cyclosporine (Neoral), and cyclophosphamide (Cytoxan). An infection should be treated with appropriate antibiotics as early as possible before it becomes serious.
Cough or chest pain
Chest pain that is caused by arthritis of the chest wall is not an emergency and does not warrant notifying the doctor immediately. However, unexplained chest pain or cough can represent serious underlying disease of the heart or lungs. It should be remembered that people with rheumatoid arthritis are at increased risk for infection of the breathing passages and lungs. Such infection requires antibiotic treatment. Furthermore, methotrexate (Rheumatrex, Trexall) can cause lung inflammation, the first sign of which is often a persistent cough. Chest pain can also be caused by the reflux of acid from the stomach into the esophagus. This condition can be aggravated by aspirin and other NSAIDs.
Note: The warning signs above are not meant to be all inclusive. There are many other symptoms of illness that also are reasons to contact the doctor urgently. For example, vision loss from a stroke or chest pain from a heart attack are reasons to contact a doctor immediately. The symptoms listed above are warning signs that occur more commonly as a result of rheumatoid disease. People with rheumatoid arthritis, therefore, should have a heightened alertness for these symptoms. They should also feel free to contact their doctor about any health issues or concerns at any time.
Klippel, J.H., et al. Primer on the Rheumatic Diseases. New York: Springer, 2008.