One of the more dangerous complications of NSAID-induced peptic ulcers is the risk of bleeding or perforation of the ulcer. A case controlled study evaluating the association of H pylori infection and bleeding peptic ulcers in current users of NSAIDs (including analgesic or antithrombotic doses of acetylsalicylic acid [ASA]) determined that NSAID users who were infected with H pylori had almost two times the risk of bleeding compared with those who were not infected with H pylori. The results of this study suggest that infection with H pylori is an independent risk factor for peptic ulcer bleeding in NSAID users. Furthermore, prospective evaluation of whether eradication of H pylori reduces the risk of recurrent peptic ulcer bleeding in high risk NSAID users demonstrated that eradication of H pylori protects against recurrent bleeding of peptic ulcers in ASA users but not in other NSAID users (Table 1).
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Comparison of maintenance acid suppression therapy with eradication of Helicobacter pylori for the prevention of recurrent bleeding of peptic ulcers in high risk users of nonsteroidal anti-inflammatory drugs (NSAIDs) or specifically acetylsalicylic acid (ASA)
|NSAID users||ASA users|
|Number of patients||53||47||34||29|
|Rebleeding||1/46(2%)*||8/41(20%)||1 /3 1(3%)||1 /2 7(3%)|
|Death||1 (2%)||0 (0%)||2 (6%)||1 (3%)|
*P<0.01. PPI Proton pump inhibitor.
The implication of H pylori in NSAID-related peptic ulcers requires further elucidation before eradication in such patients is universally indicated. Therefore, treatment with acid suppression is still required to promote ulcer healing and may also be used as prophylaxis once ulcers have healed. The current Canadian Consensus Guidelines recommend testing for H pylori and eradication therapy in all patients who present with peptic ulcers but do not recommend prophylactic eradication in ulcer-free patients who will be starting or are currently using NSAIDs. However, the Canadian guidelines do recommend prophylactic mucosal protection in patients with a high risk of developing NSAID-induced ulcers.