H pylori erdication if on aspirin

a recent article brought up the issue of H Pylori eradication in patients on low-dose aspirin (see hpylori gi bleed asa gastro 2013 in dropbox). this is an observational, prospective study looking at 3 groups of patients on low-dose asa. followed up to10 years (5K patient-yrs), primary endpoint is recurrence of gastroduod bleed.

 

--group 1: 250 pts with Hpylori and bleeding ulcer, had their Hpylori eradicated and continued with asa after the ulcer healed.

--group 2:120  Hpylori negative asa users who developed bleeding ulcers. put on enteric-coated asa after ulcer healed
--group 3: 540 pts (considered their "average risk group") new pts on asa without a hx of ulcers

 

results: incidence of ulcer bleed, per 100-pt yrs

-no diff in incidence of bleeding between group 1 (0.97 per 100 pt-yrs) and group 3 (0.66)

-group 2 (bleeding despite being h. pylori neg) with 5.22 (ie 8.5x that of the average risk group)

 

this study suggests that for ulcer re-bleeds in the first group, since it is so much lower than the h. pylori neg second group, the h pylori itself was largely responsible for the first ulcer (since the incidence then reverted to the average group rate after h pylori treatment).  so, several implicit conclusions from this not-so-fantastic study (ie, they did not randomize pts to h pylori rx vs not and watch for rebleeds): anyone with a bleeding ulcer who is h pylori positive and put back on asa should be treated for their h pylori.  and, anyone with bleeding ulcer and h pylori neg is at high risk of recurrent bleed and should be on PPI if they continue with asa therapy

 

i am bringing up this article because it raises again the issue of the utility of screening for/treating H pylori prior to starting longterm NSAID or aspirin therapy. the background: several papers over the past decade have suggested benefit from treating H pylori prior to beginning NSAIDS

 -- hpylori and nsaid lancet 2002 in dropbox is a study of 100 H pylori positive pts about to begin longterm NSAIDs. those who had the H pylori eradicated had 12% chance of ulcer on endoscopy at 6 months vs 34% in those who did not have the H pylori treated, with incidence of complicated ulcers (symptomatic/bleeding) being 4% vs 27%

--the british journal GUT came out with guidelines in 2012 (see hpylori management guidelines Gut 2012 in dropbox), which reviews the epidemiology of Hpylori and its associated clinical sequelae. a few very strong recommendations: 

    -- hpylori is assoc with increased risk of ulcers in NSAID and ASA users (grade B rec)

    --eradication reduces the risk of ulcers assoc with NSAID or low-dose ASA (grade A)

    --Hpylori eradication is beneficial before starting NSAID treatment. it is mandatory in pts with hx of PUD (grade A)

    --eradication alone does not reduce ulcers in pts already on longterm NSAIDs -- they require continued PPI Rx as well as eradication (grade A)

    --"for aspirin, even given at low dose, H pylori eradication can prevent gastropathy and should be undertaken in patients with a history of peptic ulcers...the residual risk of peptic ucer bleeding due to continued aspirin use after H pylori has been successfully treated is very low" (grade B)