Helicobacter pylori does not play a part in the dyspeptic complaints of rheumatology patients receiving long term treatment with non-steroidal anti-inflammatory drugs

Should we eradicate Helicobacter pylori before prescribing an NSAID? Result of a placebo-controlled study

OBJECTIVE

(1) To determine the prevalence of gastrointestinal (GI) symptoms in patients with and without Helicobacter pylori infection and treated with non-steroidal anti-inflammatory drugs (NSAIDs) and (2) to estimate the impact of H. pylori eradication on these symptoms.

METHODS

This was a multicentric, community-based, randomized, case-control study. Patients presenting with a rheumatic disorder motivating the prescription of an NSAID for at least 2 wks were stratified in two groups (H. pylori-positive and H. pylori-negative) by a serological doctor test and H. pylori-positive patients divided further into two subgroups, receiving either an eradication treatment (group 1) or a placebo (group 2). The main outcome measure was the prevalence of GI symptoms estimated in groups 1 and 2 and in noninfected patients (group 3) at weeks 2, 6, and 12.

RESULTS

Among H. pylori-negative patients (n=145), GI symptoms were present in 42.6%, 21.4%, and 10.0% at weeks 2, 6, and 12, respectively. In groups 1 and 2, GI symptoms were present in 57.7% and 40.7%, respectively, at week 2 (p= 0.03); 24.7% and 23% at week 6 (p= 0.85); and 9.4% and 17.3% at week 12 (p= 0.13). The prevalence of GI symptoms at week 2 was similar in group 2 and in the H. pylori-negative group (p= 0.77). The highest prevalence of symptoms at week 2 in group 1 was essentially due to diarrhea. The prevalence of GI symptoms was the same for groups 1 and 3 at week 12, and higher in group 2, but the difference did not reach statistical significance.

CONCLUSIONS

The short-term (6 wks) GI tolerance of conventional NSAIDs does not differ whether or not the patients are infected by H. pylori. The tendency observed for the medium term (12 wks) deserves to be confirmed.

[Treatment of NSAIDs related dyspepsia]

NSAIDs-induced dyspepsia occurs in 10 to 30% of patients treated with NSAIDs, leading to discontinuation of treatment in 5 to 15%. Gastrointestinal tolerability of COX-2 selective inhibitors is better than for non-selective NSAIDs. Helicobacter pylori infection does not influence gastrointestinal tolerability of NSAIDs. Therefore, patients should not be tested and treated for H. pylori infection unless they have a history of peptic ulcer. Symptoms of NSAIDs-induced dyspepsia are poorly correlated with gastroduodenal mucosal damage. Therefore, upper gastrointestinal endoscopy should be performed only if symptom relief is not achieved with the first line empirical treatment and/or if symptoms suggestive of complications, such as bleeding, develop. Proton pump inhibitors appear to be the treatment of choice for NSAIDs-induced dyspepsia.

Helicobacter pylori and nonmalignant diseases

Eradication of Helicobacter pylori has lead to a significant decrease in the prevalence of peptic ulcer disease world-wide. Despite the fact that H. pylori eradication is the only way to cure peptic ulcer disease, a substantial number of patients still need antisecretory agents to be symptoms-free after eradication. During the past year several randomized controlled trials on H. pylori eradication in patients taking NSAIDs have been published but contradictory results have been obtained. In certain parts of the world, NSAIDs are becoming the main cause of peptic ulcer disease complications such as bleeding or perforation. Some patients with nonulcer dyspepsia do benefit from eradication of H. pylori as was shown in several studies. Long-term trials with cost/efficacy analysis are still needed to demonstrate the benefit of H. pylori eradication over acid inhibition in this group of patients. H. pylori prevalence is lower in patients with gastro-esophageal reflux disease, but according to recent systematic reviews it varies geographically. There are more data now to show that eradication of H. pylori in duodenal ulcer patients does not increase the incidence of GERD. The 'test and treat' strategy for patients with uninvestigated dyspepsia was strongly supported by both meta-analysis and the results of recent randomized controlled trials. Even in developed countries where the prevalence of H. pylori decreases, this strategy allows resolution of symptoms in a larger number of patients with dyspepsia compared to empirical treatment with proton pump inhibitors and reduces the endoscopic workload.