Effects of Helicobacter pylori infection on long-term risk of peptic ulcer bleeding in low-dose aspirin users

Background & aims: Current guidelines recommend testing for Helicobacter pylori infection among users of low-dose aspirin (ASA) who are at high risk for developing ulcers. However, it is not clear whether this strategy affects long-term risk of ulcer bleeding. We assessed the utility of testing ASA users with a high risk of ulcer bleeding for H pylori infection.

Methods: In a prospective study, we recruited 3 cohorts of ASA users (≤160 mg/day). The first group included H pylori-positive users of ASAs with bleeding ulcers in whom the infections were eradicated (n = 249). They resumed ASA after ulcer healing and H pylori eradication. The second group included H pylori-negative (past and present) users of ASA who developed bleeding ulcers (n = 118). They received enteric-coated ASA after ulcer healing. The average-risk cohort included new users of ASA without a history of ulcers (n = 537). None of the subjects received regular treatment with anti-ulcer drugs. The primary end point was ulcer bleeding with ASA use in 5048 patient-years of follow-up evaluation.

Results: The incidence of ulcer bleeding (per 100 patient-years) in the H pylori-eradicated cohort (0.97; 95% confidence interval [CI], 0.53-1.80) did not differ significantly from that of the average-risk cohort (0.66; 95% CI, 0.38-0.99). The H pylori-negative cohort had a high incidence of recurrent bleeding (5.22; 95% CI, 3.04-8.96) (incidence rate ratio, 8.52; 95% CI, 4.29-16.95 vs the average-risk cohort).

Conclusions: The long-term incidence of recurrent ulcer bleeding with ASA use is low after H pylori infection is eradicated. ASA users without current or past H pylori infections who develop ulcer bleeding have a high risk of recurrent bleeding. Tests for H pylori infection can be used to assign high-risk ASA users to groups that require different gastroprotective strategies.