By: Dr. Geoffrey Modest<\/b><\/p>\n
A recent Spanish\u00a0study looked at the risk of peptic ulcer bleeding in patients with H Pylori (HP) infection and in patients also\u00a0using\u00a0NSAIDs\/low-dose aspirin (see\u00a0Am J Gastroenterol 2015; 110:684\u2013689<\/strong>). This case-control study looked at 666 patients with endoscopically-confirmed\u00a0major\u00a0peptic ulcer bleeding and 666 controls (matched by age, sex, month of admission), assessing medication\u00a0use in the prior 7 days. HP was\u00a0assessed by serology. <\/span><\/p>\n Results:<\/span><\/p>\n \u00a0<\/span>–mean age 60; 29% female; with cases having\u00a0significantly more smokers, ulcer history, dyspepsia, use of aspirin or NSAIDs, being\u00a0on anticoagulants, not being\u00a0on PPIs, and having\u00a0HP\u00a0infections (the latter being in 74.3% of cases and 54.8% of controls,\u00a0\u00a0[RR: 2.6\u00a0(CI:\u00a02.0-3.3)])<\/span><\/span><\/p>\n –aspirin use (<300 mg\/d) was associated with 15.8% of cases vs 12% of controls [RR: 1.9 (CI:\u00a01.3-2.7)]. <\/span><\/p>\n –NSAID use was associated with 34.5% vs 13.4% of controls\u00a0[RR: 4.0\u00a0(CI:\u00a03.0-5.4)]<\/span><\/span><\/p>\n –aspirin use plus HP\u00a0infection did not further\u00a0increase the risk of bleeding\u00a0\u00a0[RR:3.5\u00a0(CI:\u00a02.0-6.1)]<\/span><\/p>\n –NSAID use plus HP\u00a0infection did\u00a0increase\u00a0the risk of bleeding in at least\u00a0an additive manner\u00a0[RR: 8.0\u00a0<\/span><\/strong>(CI:\u00a05.0-12.8)]<\/span>\u00a0<\/span><\/p>\n –subgroup analysis of those on\u00a0aspirin\u00a0>500 mg\/d found similar results to NSAIDs<\/span><\/p>\n –so, their conclusion: the risk of documented peptic ulcer\u00a0bleeding was dramatically increased in those with\u00a0H Pylori infection determined serologically who were on NSAIDs but not on low-dose aspirin<\/span><\/p>\n Here are a few older articles on this subject:<\/span><\/p>\n –the first I saw: a\u00a01997 RCT in the Lancet looked at 202\u00a0patients with musculoskeletal pain who were going to be put on NSAIDs. These patients did not have prior\u00a0NSAID exposure and did have\u00a0endoscopically-documented but asymptomatic\u00a0H Pylori infection. The researchers then assessed the incidence of GI bleeding in the group\u00a0given H Pylori eradication meds\u00a0vs those given placebo treatment, finding\u00a0that the development of endoscopically-proven\u00a0GI ulcers\u00a0occurred\u00a0in 26% of those with persistant HP and only 3% in those with HP eradicated\u00a0(see\u00a0Lancet 1997; 350: 975\u201379<\/strong><\/span>).<\/span><\/p>\n —The American College of Gastroenterology published practice guidelines in 2009 which supported the conclusion that there is an additive role of H Pylori infection in those on NSAIDs\u00a0in the development of ulcers and that 2 systematic reviews have shown that HP eradication is superior to placebo in preventing peptic ulcers among NSAID users.They comment\u00a0that there is a potential advantage to H pylori testing and that\u00a0then using either a gastroprotective agent or eradicating H Pylori may be useful depending on the individual’s underlying GI risk\u00a0(see\u00a0Am J Gastroenterol 2009; 104:728 \u2013 738)<\/span>\u200b\u200b<\/span><\/p>\n –also there have been\u00a0several articles in my BMJ\u00a0blog (for\u00a0articles on treatment issues, see\u00a0here<\/a>. For an article on potential benefits in reducing gastric cancer,\u00a0see here<\/a>.)<\/span><\/p>\n So, what can one conclude?<\/span><\/p>\n –One could adopt the posture, as I do, that we should be screening and treating patients with HP more rigorously, with part of\u00a0the rationale being\u00a0that many people (perhaps, way too many) take a lot of\u00a0NSAIDs and the data are pretty impressive that treating the HP infection decreases the risk of bleeding (though another angle is to gastroprotect everyone with a PPI, or possibly high-dose histamine-blocker — though I personally don’t fancy the idea of treating a potential complication of a med with another med, which in itself may have some adverse effects, such as osteoporosis, increased pneumonia, etc. I\u00a0do very strongly try to limit use of NSAIDs in my patients as much as I can persuade them, given not just the GI effects, but effects on hypertension, heart failure, kidneys… \u00a0Also, as an aside and pretty anecdotal report: I saw a small\u00a0clinical research study in the Lancet about 20-25 years ago showing dramatic resolution of ITP (idiopathic thrombocytopenic purpura) if one treats an underlying\u00a0HP infection (in those infected). Then, about 2 weeks after seeing this, I had an Irish patient from Boston who had prednisone-resistant ITP, but (unexpectedly) had positive HP antibodies, got treatment for HP, and the ITP (with persistent platelet count in the 20,000 range and lots of ecchymoses) vanished and did not recur to date.<\/span><\/p>\n –The data on aspirin are reasonably consistent that there is not a clear additive effect with HP infection. One could still\u00a0<\/span>consider gastroprotection just because of the gastric effects of aspirin. I\u00a0do reinforce with patients\u00a0that low-dose aspirin is associated with GI bleeding, and that it is still prudent to avoid other GI irritants (smoking, alcohol, NSAIDs, etc). And, by the way, there are some concerns that enteric-coated aspirin may not be as\u00a0effective for cardioprotection\u00a0as regular 81mg aspirin and is no more gastroprotective. \u00a0See here\u00a0<\/a>for details.\u200b<\/span><\/p>\n \n","protected":false},"excerpt":{"rendered":" By: Dr. Geoffrey Modest A recent Spanish\u00a0study looked at the risk of peptic ulcer bleeding in patients with H Pylori (HP) infection and in patients also\u00a0using\u00a0NSAIDs\/low-dose aspirin (see\u00a0Am J Gastroenterol 2015; 110:684\u2013689). This case-control study looked at 666 patients with endoscopically-confirmed\u00a0major\u00a0peptic ulcer bleeding and 666 controls (matched by age, sex, month of admission), assessing medication\u00a0use […]<\/p>\n