DEAR DR. ROACH: I’m a 67-year-old male and have had swollen hands for several weeks, the worst in the early morning. I take lisinopril and atenolol for my blood pressure and have taken ibuprofen twice a day since this started, two pills at a time. Do you have any ideas about what this could be? And how does a doctor find a diagnosis of these symptoms? — J.H.
ANSWER: New onset swelling localized to the hands, especially in the morning, makes me think of inflammatory arthritis or crystal arthropathy. While it’s always good to think about medication effects, swelling in the hands would be very unusual for either lisinopril or atenolol.
The most common inflammatory arthropathies are rheumatoid arthritis and psoriatic arthritis, but systemic lupus may also cause inflammation. Atenolol is occasionally associated with drug-induced lupus, although joint symptoms are even less common.
The evaluation starts with a careful history and physical exam, especially finding out what in the hands is swollen. In rheumatoid arthritis, it is the lining of the joints — the synovium — that is commonly affected, and an experienced clinician can detect this on an exam. X-rays and blood tests help confirm the diagnosis. They are also helpful (as is an examination of the skin and nails) to make the diagnosis of psoriatic arthritis.
Gout and pseudogout are the crystal arthropathies, meaning that the joints become inflamed because crystals form inside the joint. Classically, the big toe is the affected joint in gout, while large joints, like the knees, are most commonly affected in pseudogout. But both may affect the hands. X-rays, and sometimes removal of fluid from the joint, will make this diagnosis. Other types of arthritis certainly can affect the hand, but the sudden onset is suspicious for one of these inflammatory conditions.
If there is swelling in the feet or in other parts of the body, then the list of potential causes becomes much larger, including kidney, liver and heart diseases, so it’s really important to get checked out by your general doctor, who may want to make a consultation if the answer is not apparent.
DEAR DR. ROACH: A recent column touched on the combination of Tylenol and Advil. You advised the writer that he should be OK with those low doses. I have the same problem as him. Since then, I read a report that the FDA announced a change regarding combinations of Tylenol and an opioid because of major liver failure. They reduced the Tylenol dosage to 325 mg. I would appreciate a clarification on the safe doses of Tylenol and Advil for pain. — H.H.
ANSWER: The reason the FDA limited the amount of acetaminophen (Tylenol) in combination with opioid products (such as Percocet, Vicodin or even codeine) is that many people who use these preparations were also taking regular Tylenol — and the amount of Tylenol that a person in pain could take over a day was sometimes over the safe amount. Since they made this change, the number of admissions to the hospital for liver failure due to excess Tylenol in combination with opioids decreased by 16%.
This is a separate issue from the combination of Tylenol with anti-inflammatories like ibuprofen (Advil and many others), although there are combination pain medicines that contain Tylenol (such as Excedrin), as well as many combination products for cold and flu symptoms that contain Tylenol. So, it’s still worthwhile to make sure that you aren’t taking excess Tylenol. (Nobody should exceed 4,000 mg of Tylenol a day, combined from all products, and people at a higher risk should stay below 2,000 mg, or at a dosage directed by their doctor.)
Sudden onset of swollen hands occurs early in the morning
A reader's swollen hands may be due to inflammatory arthritis or crystal arthropathy, Dr. Keith Roach surmises. There are other potential causes, although it would be unusual if it were tied to blood pressure medicine.
