HERNE, Germany—Rheumatologists should test potential NSAID users for Helicobacter pylori infection and eradicate the ulcer-causing bacterium before beginning NSAIDs, according to a review study in Rheumatology.1 Eradication of H. pylori will not completely protect long-term NSAID users with recent ulcer complications from recurrent problems, however.

“It’s never too late to treat H. pylori, and if you find it, you should treat it.”—Gurkirpal Singh, MD
“Ulcer risk reduction after H. pylori eradication therapy is clearly more marked in patients beginning NSAID therapy than in patients who were already receiving and tolerating NSAID therapy,” report the researchers led by Uta Kiltz, MD, of St. Josefs Hospital in Herne Germany. “The management of H. pylori infection and the prevention of gastrointestinal (GI) complications in NSAID users need to be individualized on the basis of recently published data.”

The new review comprised seven randomized controlled trials and one meta-analysis (including three papers on NSAID-naïve patients). NSAID-naïve users benefit from testing for H. pylori infection and subsequent eradication therapy prior to the initiation of NSAIDs. In these patients, eradication of H. pylori does reduce the incidence of GI bleeding.

H. pylori eradication alone does not protect chronic NSAID users with recent ulcer complications from further GI events. Long-term acid suppressive therapy is needed to prevent recurrent ulcer bleeding in this patient population, the study authors conclude. “[Proton pump inhibitor] therapy is superior to the eradication of H. pylori for secondary prevention of upper GI bleeding in H. pylori-infected patients who continue to take NSAIDs.”

Translating research into practice

Although the role of H. pylori in the pathogenesis of NSAID-induced gastroduodenal lesions is controversial, “the conclusions [of the review study] are fairly robust, and this is very similar to guidelines that others such as the American Gastroenterological Association are suggesting,” said Gurkirpal Singh, MD, an adjunct clinical professor of medicine, division of gastroenterology and hepatology at Stanford University School of Medicine in Palo Alto, California.

“The bottom line is to treat H. pylori in the same way in NSAID patients as you would in non-NSAID patients,” Dr. Singh told MSKreport.com. “It’s never too late to treat H. pylori, and if you find it, you should treat it.”

Reference
1. Kiltz U, Zochling J, Schmidt WE, Brain J. Use of NSAIDs and infection with Heliobacter pylori—what does the rheumatologist need to know? Rheumatology. 2008;47:1342-1347.