Commentary

Even low doses of aspirin can cause serious ulcer complications. H pylori infection, which is a risk factor for aspirin associated ulcers,¹ is more prevalent in Hong Kong (where the study by Lai et al was done) than in North America. Lai et al showed that eradication of H pylori infection alone was inadequate for preventing recurrence of ulcer complications in Chinese patients who were restarted on low dose aspirin after ulcer healing. The combination of H pylori eradication and subsequent maintenance with lansoprazole was substantially superior to H pylori eradication alone in preventing ulcer complications within 1 year. We do not know the “natural” rate of recurrent ulcer complications without either of these interventions because the inclusion of a control group in which patients were not offered treatment for H pylori infection would have been unethical.

A recent multinational study (currently only available in abstract form) found a point prevalence of endoscopic ulcers of 11% in patients who were receiving aspirin, 75–325 mg/day, but not nonsteroidal anti-inflammatory drugs, proton pump inhibitors, or H₂ antagonists.¹ Advancing age and H pylori infection were risk factors for ulcers while dyspepsia was a negative predictor. Therefore, some patients receiving low dose aspirin (particularly the elderly and those who are asymptomatic) will have ulcers and will be at risk for complications. This does not mean that they all require long term treatment with proton pump inhibitors. However, those who have an ulcer complication should be tested for H pylori infection, which should be treated if present. For such patients who are resuming low dose aspirin because of a medical necessity, long term proton pump inhibitor co-therapy after documented ulcer healing and H pylori eradication is recommended.