Symptoms and new meds align, but are drugs the culprit?

DEAR DR. ROACH >> Following placement of two stents in my arteries (not my heart), my cardiac physician has me on an 81-mg aspirin and 75 mg of clopidogrel daily. I am much weaker during my exercise class, fall asleep in the late morning and am utterly unable to have sex. My primary physician is adamant that aspirin does not cause loss of strength. He did not comment on my sexual problem, except to refer me to my urologist, who simply ascribed it to my age (84). I take self-injected Praluent with no side effects. I am fairly certain the blood thinner is the cause of my problem, but my cardiologist insists I take it until “my last breath.”

My questions are whether a full aspirin is as effective as baby aspirin plus clopidogrel, and whether the clopidogrel could be the cause of the erectile dysfunction. — D.R.W. DEAR READER >> It’s impossible to say with certainty that any of your medications — aspirin, Praluent or clopidogrel — are NOT causing your symptoms. However, none of them are well known for doing so. For example, less than 0.2 percent of reported side effects with clopidogrel (among the minority of people who reported a side effect) were about sexual dysfunction. It sounds like the timing of your symptoms coincides with starting the medicine, which is good evidence that there may be a connection. However, there are at least two other possibilities.

The first is that the procedure itself, or the underlying condition, caused the symptoms. Stents are placed in arteries to relieve blockages, which cause poor blood flow. Poor blood flow is certainly a cause of erectile dysfunction. I don’t know what arteries you had stented, but it is certainly possible that the blood flow to the penis is inadequate for sexual function. Your urologist could test that (I hate to secondguess your doctor, but every time I hear that a physician has ascribed symptoms to a patient’s age, I worry that something might be missed).

The second possibility is that when people expect a side effect from a medication, it can come on. This is called the “nocebo effect,” and it shows how powerfully the mind and body are linked.

The question about switching to aspirin only is for your cardiologist. It depends on the type of stent (a drug-eluting stent will require a longer period on clopidogrel), and the optimum treatment is not clear from medical studies. There may be other options besides clopidogrel.