Helicobacter pylori and nonsteroidal anti-inflammatory drugs: a three-way debate

Randomised clinical trial: rabeprazole plus aspirin is not inferior to rabeprazole plus clopidogrel for the healing of aspirin-related peptic ulcer

BACKGROUND

Clopidogrel does not inhibit prostaglandin synthesis. As a result, clopidogrel's incidence of peptic ulcer disease (PUD) and ulcer bleeding is lower than aspirin's.

AIM

To compare the healing rate in aspirin-related dyspeptic ulcer patients who were given proton pump inhibitor (PPI) plus aspirin or PPI plus clopidogrel.

METHODS

Patients with aspirin-related nonbleeding symptomatic ulcers were randomised to receive rabeprazole (20 mg/day) plus aspirin (100 mg/day) or rabeprazole (20 mg/day) plus clopidogrel (75 mg/day) for 12 weeks. The primary endpoint was the successful treatment of PUD as characterised by intention-to-treat at the end of therapy.

RESULTS

Two hundred and eighteen patients (109 in the aspirin group and 109 in the clopidogrel group) were enrolled. There were no statistical demographic differences between the group that received aspirin and the group that received clopidogrel. The PUD treatment success rate was also statistically equal between the clopidogrel and aspirin groups (86.2% vs. 90.0%, P = 0.531). Neither group experienced ulcer-related bleeding. Multivariate logistic regression analysis showed that large ulcer size (>10 mm) (OR: 6.29, 95% CI: 2.58-15.37) and past history of PUD (OR: 3.69, 95% CI: 1.24-10.97) were important predictors of unsuccessful therapy for aspirin-related PUD.

CONCLUSIONS

Rabeprazole plus aspirin is not inferior to rabeprazole plus clopidogrel in treating aspirin-related symptomatic PUD. Large ulcer size (>10 mm) and past history of PUD are important predictors of unsuccessful therapy (NCT 01037491).

Striving for euthyroidism in radioiodine therapy of Graves' disease: a 12-year prospective, randomized, open-label blinded end point study

BACKGROUND

In China, use of radioiodine therapy is problematic because of the need for lifelong levothyroxine substitution. Our aim was to find an optimum dosing strategy for (131)I treatment of hyperthyroidism due to Graves' disease (GD). We attempted to achieve euthyroidism to avoid long-term levothyroxine treatment.

METHODS

Six hundred patients with GD were randomized into five groups, each comprising 120 individuals, to receive an individual (131)I activity selected from five different ascending activity ranges. The ranges were modulated according to a clinical score system. Follow-up was extended over a 12-year time frame. The primary outcomes were euthyroidism, hyperthyroidism, hypothyroidism, and recurrent hyperthyroidism. The secondary endpoint was the accumulated (131)I activity needed to achieve euthyroidism.

RESULTS

Out of 682 screened patients, 600 entered the study in 1997. Five hundred twenty-nine completed the last follow-up visit at the end of the study in 2009. Group 3 was identified as the study arm that received the optimum radioiodine activity, with 71.8% of the patients maintaining a euthyroid status, 5.8% remaining hyperthyroid, and 22.3% becoming hypothyroid by the end of the study. This group received 1.85-4.07 MBq per gram of thyroid tissue (average administered activity 261 ± 162 MBq). Over the 12-year follow-up period, the recurrence rate was 13.6%. The efficacy of (131)I treatment was related to activities modulated by a clinical score (χ(2) = 82.1, p = 0.000).

CONCLUSION

Our protocol effectively treated hyperthyroidism and significantly reduced the hypothyroidism rate. It may be preferable to the intentional induction of permanent hypothyroidism recommended by many experts.

Gastritis increases resistance to aspirin-induced mucosal injury via COX-2-mediated lipoxin synthesis

Products of cyclooxygenase (COX)-2 contribute to mucosal defense. Acetylation of COX-2 by aspirin has been shown to result in the generation of 15(R)-epi-lipoxin A4, which exerts protective effects in the stomach. In gastritis, it is possible that lipoxin A4 makes a greater contribution to mucosal defense. We tested this hypothesis in the rat, by using the iodoacetamide-induced gastritis model. Iodoacetamide was added to the drinking water for 5 days. Rats were then given aspirin, and the extent of gastric damage was blindly assessed 3 h later. Gastric 15(R)-epi-lipoxin A4 and PGE2 levels were determined. The effects of pretreatment with a selective COX-2 inhibitor, rofecoxib, and of a lipoxin receptor antagonist were assessed. Effects of aspirin and the other test drugs on leukocyte adherence within mesenteric venules were assessed by intravital microscopy. Aspirin elicited greater lipoxin synthesis in the inflamed than in the normal stomach, and there was reduced gastric damage. Rofecoxib inhibited lipoxin synthesis and exacerbated aspirin-induced damage. The lipoxin antagonist also exacerbated aspirin-induced damage. In rats with gastritis, aspirin reduced leukocyte adherence (in contrast to an increase in normal rats), and this effect was reversed by rofecoxib or by the lipoxin antagonist. These results support the notion that aspirin-triggered lipoxin synthesis via COX-2 makes an important contribution to mucosal defense in both the normal and inflamed stomach.

Helicobacter pylori: when is treatment now indicated?

The prevalence of Helicobacter pylori in Western societies has rapidly declined, as reflected by the consistent decline in peptic ulcer disease. Nevertheless, there remains a cohort of the elderly population with a high prevalence of H. pylori infection. While the benefits of H. pylori eradication for H. pylori-associated duodenal ulcer disease is beyond dispute, a number of contentious areas remains. The aim of the present paper is to review the benefits of H. pylori eradication in clinical situations that may confront the non-gastroenterologist.

Review article: Helicobacter pylori infection in peptic ulcer haemorrhage

In this overview, medical advice for routine clinical practice regarding peptic ulcer haemorrhage (PUH) is given, based on the extensive literature about Helicobacter pylori and the controversial results about the interaction of H. pylori infection and nonsteriodal anti-inflammatory drug (NSAID) use. PUH remains an important emergency situation with an incidence between 32 and 51/100 000 persons per year. There is a high association between H. pylori infection and peptic ulcer disease. The association between H. pylori infection and PUH is less clear, but a strong argument for the aetiological role is the fact that eradication of H. pylori decreases recurrence of bleeding. NSAID use is another important risk factor for PUH. H. pylori infection and NSAID use seem to act independently, although some studies show a synergistic interaction while other studies report that H. pylori is protective against the development of PUH in NSAID users. All patients with PUH should be tested for H. pylori infection, regardless of the use of NSAIDs. Because invasive tests are less sensitive in PUH patients, negative tests in patients with no other risk factors should be confirmed by serology or urea breath test (UBT). Eradication therapy with a proton pump inhibitor or ranitidine bismuth citrate-based triple therapy should be given to all H. pylori-positive patients. Only for nonaspirin-NSAID users does the effect of eradication therapy on the healing of gastric ulcers remain controversial, but currently we also advise eradication of H. pylori in this subgroup. After eradication therapy, acid-suppressant therapy is advised to heal the ulcer. The success of eradication should always be confirmed because of the risk of recurrence of peptic ulcer disease and bleeding in H. pylori-infected patients.