6Interaction of Helicobacter pylori infection and low-dose aspirin in the upper gastrointestinal tract: Implications for clinical practice
Section snippets
Clinical scenario
A general health practitioner calls you concerning a 72-year-old male patient on low-dose aspirin for known ischaemic heart disease. Past medical history reveals a peptic ulcer bleed 1 year ago. Helicobacter pylori status is unknown. Before testing for H. pylori, your colleague wishes to know if H. pylori increases the risk of low-dose aspirin related gastrointestinal injury and whether eradicating it would be beneficial.
Pathophysiology of upper GI injury
Low-dose ASA and H. pylori damage the gastric mucosa by mechanisms that may be distinct or shared. The mechanism of low-dose ASA induced upper GI injury is incompletely understood, however, low-dose ASA likely exerts both systemic and topical effects that may interact with H. pylori in a synergistic or antagonistic manner [1], [2], [3], [4], [5], [6], [7], [8] (Table 1).
H. pylori positive low-dose ASA users: clinical studies
Literature is sparse and controversial concerning the interaction of H. pylori and low-dose ASA in causing upper GI injury. A recent systematic review including 13 studies by Fletcher et al [18] concluded that the current available evidence was insufficient to perform a meta-analysis and that no firm conclusion could be drawn regarding the impact of H. pylori on upper GI bleeding risk in ASA users. Indeed ten of 13 studies examined were cohort studies that comprised a heterogeneous group with
Data from NSAID studies
Two meta-analyses lend indirect support to the role of H. pylori in upper GI complications in low-dose ASA users. In a meta-analysis by Huang et al [25] including 16 studies that collectively enrolled 1652 NSAID users, peptic ulcer disease was significantly more common in patients positive than in those negative for H. pylori. The presence of both H. pylori and NSAIDs increased the risk of ulcer bleeding 6.13-fold whereas H. pylori alone and NSAIDs increased the risk of ulcer bleeding 1.79-fold
Concomitant use of NSAIDs, anti-coagulants and other anti-platelet drugs
Several studies have shown that the risk of ulcer rebleeding is significantly increased in patients on low-dose ASA and concomitant use of NSAIDs, anticoagulants or other anti-platelet drugs [1], [2], [3]. There are no studies specifically examining the risk reducing benefit of H. pylori eradication in these patients either for primary or secondary prophylaxis.
It would be reasonable to suggest H. pylori eradication in low-dose ASA users on concomitant NSAIDS if there are indications for
Cost-effectiveness of test and treating H. pylori
There are currently no studies specifically addressing the cost-effectiveness of test and treating H. pylori in low-dose ASA users. However, in a decision analysis model of test and treating H. pylori for patients requiring chronic NSAID therapy [30], this strategy could reduce NSAID-related adverse events for average risk patients at an acceptable incremental cost. The clinical and cost-effectiveness benefit was also shown to increase with increasing ulcer risk. Another UK report [31] showed
Recommendations by consensus groups
A certain degree of misinformation may surround the risk and benefit of gastroprotective strategies in NSAID and low-dose ASA users [32]. In an aim to standardize our approach to this matter, various consensus groups have developed recommendations concerning the management of H. pylori [33], [34], [35] and concerning GI risk reduction in NSAID and antiplatelet users [36], [37].
It is acknowledge that the interaction between H. pylori infection and NSAIDs including low-dose ASA in peptic ulcer
Summary
In the clinical scenario presented, the patient has several risk factors for recurrent peptic ulcer bleeding, namely a previous history of ulcer bleed, advanced age, and on-going use of low-dose ASA. In line with current evidence and international guidelines, we would suggest testing and treating the patient for H. pylori. It would also be reasonable to consider a long-term gastroprotective agent in view of his multiple risk factors (Table 3).
It is important to acknowledge that a substantial
Conflicts of interest
None declared.
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Cited by (21)
Helicobacter pylori eradication for primary prevention of peptic ulcer bleeding in older patients prescribed aspirin in primary care (HEAT): a randomised, double-blind, placebo-controlled trial
2022, The LancetCitation Excerpt :However, although anti-inflammatory doses of aspirin are intrinsically ulcerogenic, the much lower doses used for prevention of thrombosis are less damaging.11 There is evidence that Helicobacter pylori might play a central role in the development of peptic ulceration12–15 and ulcer bleeding16–18 in patients receiving aspirin, but these data are largely observational and a causal role has not been established. These studies suggest eradication of H pylori as a therapeutic target to prevent peptic ulceration and ulcer bleeding, but randomised controlled trials have been limited to secondary prevention of recurrent ulcer bleeding and have yielded discordant results.19,20
The contribution of clinical and pathological predisposing factors to severe gastro-duodenal lesions in patients with long-term low-dose aspirin and proton pump inhibitor therapy
2017, European Journal of Internal MedicineCitation Excerpt :Although the role of PPI in preventing gastrointestinal lesions occurrence has been well demonstrated [5,8,10], we investigated the remnant factors that can influence severe gastro-duodenal lesions occurrence, as the frequency of these lesions was 27.4% in our series, higher than in the majority of reported data [11,12]. Adherence to preventive strategies in patients treated with antiplatelet therapy [5] increased the number of patients with concomitant LDA + PPI therapy, but the efficiency of PPI preventive strategies in a population with a high prevalence of H. pylori infection and different phenotypes of gastritis is questionable, as the complex interplay among infection and concomitant therapies is debatable [13,14]. Data regarding gastrotoxic or gastroprotective drug consumption, drug related GI lesions or bleeding arising from the eastern part of Europe are not consistent [13].
Helicobacter pylori Infection and Nonsteroidal Anti-inflammatory Drug Use: Eradication, Acid-Reducing Therapy, or Both?
2012, Clinical Gastroenterology and HepatologyAspirin: The balance between benefits and harms
2012, Best Practice and Research: Clinical GastroenterologyHelicobacter pylori eradication for primary prevention in older patients
2023, Medizinische Monatsschrift fur Pharmazeuten
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