Helicobacter pylori infection and nonsteroidal anti-inflammatory drug use: eradication, acid-reducing therapy, or both?

Management of NSAID-associated peptic ulcer disease

Non-steroidal anti-inflammatory drug (NSAID) use increases the risk of gastrointestinal complications such as ulcers or bleeding. The presence of factors like advanced age, history of peptic ulcer, Helicobacter pylori infection and the use of anticoagulants or antiplatelet agents increase this risk further. COX-2 inhibitors and antisecretory drugs, particularly proton pump inhibitors, help to minimize the risk of gastrointestinal complications in high-risk patients. This review presents a practical approach to the prevention and treatment of NSAID-associated peptic ulcer disease and examines the new advances in the rational use of NSAIDs.

Helicobacter pylori infection in nonsteroidal anti-inflammatory drug users

NSAID-induced upper gastrointestinal (GI) damage occurs easily in people with a prior history of complicated or uncomplicated ulcers. Many recent clinical studies have proved the benefit of Helicobacter pylori eradication in NSAID users; however, the exact pathophysiologic relationship between concomitant H. pylori infection and NSAID use has not yet been fully elucidated. Testing and eradication of H. pylori are generally recommended in patients who are at a high risk for NSAID-induced GI damage. However, in high-risk patients, ulcer prophylaxis with proton pump inhibitor or misoprostol is needed even if H. pylori has been successfully eradicated. In low-risk patients, it is still questionable whether or not eradication of H. pylori can reduce upper GI damage. However, in western countries, due to its cost effectiveness, testing and eradication of H. pylori is recommended before starting aspirin or NSAID irrespective of the risk level. In regions with a high prevalence of H. pylori infection (>20%), the usefulness of testing and eradication of H. pylori has not yet been determined.

Aspirin and non-aspirin NSAIDs increase risk of colonic diverticular bleeding: a systematic review and meta-analysis

Lower gastrointestinal bleeding is a frequent cause of hospitalization, particularly in the elderly, and its incidence appears to be on the rise. Colonic diverticular bleeding is the most common form of lower gastrointestinal bleeding and is responsible for 30-40 % of bleeding episodes. Risk factors associated with diverticular bleeding include obesity, hypertension, anticoagulants, diabetes mellitus, and ischemic heart disease. Recent studies have suggested a relationship between usage of non-steroidal anti-inflammatory drugs (NSAIDs) and colonic diverticular bleeding; however, most studies were small with wide confidence intervals. We identified studies by searching the PubMed and Scopus databases (from inception through 31 December 2012) and by searching bibliographies of relevant articles. Summary relative risks (RRs) with 95 % confidence intervals (CIs) were calculated with fixed-effects and random-effects models. A total of six studies (five case-control studies and one cohort study) met inclusion criteria for analysis. Non-aspirin NSAIDs (NANSAIDs) and aspirin were associated with an increased risk of colonic diverticular bleeding (summary RR = 2.48, 95 % CI 1.86-3.31), with moderate heterogeneity among these studies (P heterogeneity = 0.11, I (2) = 44.4 %). Stratification to evaluate the heterogeneity found that both NANSAIDs (summary RR = 2.24, 95 % CI 1.63-3.09; 5 studies) and aspirin (summary RR = 1.73; 95 % CI 1.31-2.30; 3 studies) were associated with the risk of diverticular bleeding. Aspirin/NANSAIDs use was strongly and consistently associated with an increased risk of colonic diverticular bleeding. Further studies are needed to stratify individuals at risk of diverticular bleeding associated with the use of these agents.