H pylori and Peptic Ulcer in Low-Dose Aspirin Users: Testing Useful

Current guidelines recommending Helicobacter pylori testing in low-dose aspirin (ASA) users at high risk for peptic ulcer have not been based on solid clinical studies. This 10-year prospective observational study confirmed the usefulness of testing for H pylori on the basis of a decreased long-term incidence of ulcer bleeding.

Three cohorts were followed:

1. H pylori–positive post-eradication ulcer: 249 H pylori–positive users of low-dose ASA with bleeding ulcers in whom infections were eradicated. The patients resumed ASA use after ulcer healing.

2. H pylori–negative ulcer: 118 H pylori–negative users of low-dose ASA in whom bleeding ulcers developed. The patients resumed ASA use after ulcer healing.

3. Nonulcer: 537 new users of ASA with no history of ulcers.

None of the patients received prophylactic antiulcer drugs. The primary end point was ulcer bleeding with ASA use in 5048 patient-years of follow-up.

The incidence of recurrent bleeding ulcer (per 100 patient-years) in the H pylori–positive, posteradication cohort did not differ significantly from the risk of first-time ulcer in the nonulcer cohort. In contrast, the H pylori–negative ulcer cohort had a markedly higher incidence of recurrent ulcer compared with the other 2 cohorts.

To restate: In postulcer patients using ASA, eradicating H pylori induces a lower risk state than never having had documented H pylori in the first place.

The findings suggest that these 2 cohorts had their initial ulcer for different reasons. In the H pylori–positive group, the ulcer presumably was the result of H pylori. In the H pylori–negative group, the ulcer was the result of susceptibility of the cohort to the GI toxicity of low-dose ASA.

The results have implications for gastroprotective strategies being considered for patients who are starting low-dose ASA therapy.

The authors suggest the following:

• H pylori–positive patients should receive anti–H pylori therapy followed by confirmation of eradication. They do not need gastroprotective therapy with proton pump inhibitors (PPIs) while they are receiving ASA.

Exceptions are noted: PPIs should be considered if there are concomitant NSAIDs, anticoagulants, corticosteroids, or other antiplatelet drugs.

• H pylori–negative patients (confirmed by serology) should receive adequate gastroprotective therapy with PPIs if they have a history of ulcer because they are prone to ulcer with ASA use.

The study will likely solidify recommendations for H pylori testing in existing guidelines.

Source: Chan FK, Ching JY, Suen BY, et al. Effects of Helicobacter pylori infection on long-term risk of peptic ulcer bleeding in low-dose aspirin users. Gastroenterology. 2013;144:528-535.

The abstract is available here.