A meta-analysis also published in this week's issue confirms both H. pylori and NSAIDs as independent risk factors for peptic ulcer disease.
Whether H. pylori increases the risk of ulcers in patients taking NSAIDs is controversial.
Francis Chan and colleagues from Prince of Wales Hospital, Hong Kong, hypothesized that eradication of H. pylori would reduce the risk of ulcers for patients starting long-term NSAID treatment.
Patients requiring long-term NSAIDs were randomly assigned omeprazole triple therapy (eradication group) or omeprazole with placebo instead of antibiotics (placebo group) for 1 week.
All patients were given diclofenac slow release 100 mg daily, for 6 months from randomization.
Endoscopy was done at 6 months or if severe dyspepsia or gastrointestinal bleeding occurred.
The primary endpoint was the probability of ulcers within 6 months.
Of 210 arthritis patients screened, 100 patients were enrolled in the study.
H. pylori was eradicated in 90% of the eradication group and 6% of the placebo group. Five of 51 eradication-group patients and 15 of 49 placebo-group patients had ulcers.
|Increased risk of ulcer bleeding:|
With H. pylori infection: 1.8-fold
With NSAID use: 4.9-fold
H. pylori and NSAIDs: 6.1-fold
The 6-month probability of ulcers was 12% in the eradication group and 34% in the placebo group. The corresponding 6-month probabilities of complicated ulcers were 4% and 27%, respectively.
A meta-analysis by Richard Hunt and colleagues from McMaster University Medical Center, Canada, pooled data from previous studies about H. pylori, NSAID use, and peptic ulcer disease.
In 16 studies of 1625 NSAID takers, uncomplicated peptic ulcer disease was more than twice as likely in patients positive for H. pylori than in those negative for H. pylori.
H. pylori infection and NSAID use increased the risk of ulcer bleeding 1.79 and 4.85 fold, respectively.
However, the risk of ulcer bleeding increased by a factor of 6.13 when both factors were present.
In an accompanying Commentary, Professor Roy Pounder discusses the management options for these patients.