Dear Dr. Roach: I am an 84-year-old man and have had atrial fibrillation for many years. In 2022, I had the WATCHMAN procedure. Prior to the WATCHMAN implant, I took Eliquis to help prevent strokes. During this time, I never had an issue with purpura spots. After the WATCHMAN, I took Plavix for six months and had many occurrences of purpura.
I stopped taking Plavix in October 2022, but continued to have issues with purpura spots, primarily on my hands and arms when I accidentally rub too hard or bang against something solid. When I told my cardiologist about the problem, he said my skin was getting thinner. In my opinion, this was an unsatisfactory answer. I find it hard to believe that my skin suddenly got so much thinner in six months that I now have this problem. I believe the issue is related to Plavix and that it is having a permanent after-effect. What is your opinion?
E.S.
Plavix works by reducing the effectiveness of platelets, the blood-clotting cells. This makes bruising easier. Eliquis works on blood-clotting factors, so it doesn’t really cause the type of bruising you have now.
Many people in their 80s have your exact issue, called “solar purpura.” The skin on the top of the hands, wrists and arms gets damaged by decades of sun exposure and can easily bruise. The Plavix you took is long gone and can’t be causing problems now, and it doesn’t cause permanent damage either. So, I agree with your cardiologist, but I do wonder if you are taking aspirin, which also affects platelets and would increase the risk of these superficial bruises.
Dear Dr. Roach: Have there been randomized, controlled studies about taking calcium supplements in people with osteoporosis? Do they really make a meaningful difference?
M.A.
T-hat’s a deceptively simple question with a complicated answer.
First off, calcium is not generally given alone; it’s given in combination with vitamin D. Vitamin D improves absorption of calcium and phosphate, the main mineral components of bone. In studies of people with osteoporosis who were given combination calcium and vitamin D, bone density tends to get better.
However, this doesn’t necessarily translate into the main goal, which is the prevention of fracture. When looking at all studies, people in nursing homes (who have a high risk of low vitamin D) received a benefit with combined calcium and vitamin D, while people who lived in the community did not have a reduced risk of fracture. Nearly all of these studies have been done on women only.
A potential concern about calcium supplementation has been that some studies have shown an increased risk of heart disease, while other studies haven’t. My opinion is that if there is harm to the heart from calcium supplementation, it is likely to be small. Still, there is no increase in heart risk from a high-calcium diet, so I prefer that my patients get their calcium primarily from food, if possible.
It’s also critical to remember that in studies using bisphosphonate drugs, like alendronate, all patients received supplemental calcium and vitamin D. These studies showed reduced fracture rates. To follow evidence-based medicine, we recommend our patients get adequate calcium and vitamin D.
Murray Favus, one of my medical school professors who was part of the team that did the studies proving the benefit of bisphosphonates, told me that without adequate calcium, these medicines can cause bone pain.
Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to [email protected]
