Correspondence

Lansoprazole for the Prevention of Recurrences of Ulcer Complications from Long-Term Low-Dose Aspirin

N Engl J Med 2002; 347:1623-1624November 14, 2002

Article

To the Editor:

Lai et al. (June 27 issue)1 report that lansoprazole after the eradication of Helicobacter pylori was significantly better than eradication alone in decreasing the risk of recurrence of ulcer complications in patients with long-term low-dose aspirin use. In their study, 61 patients were randomly assigned to receive placebo after therapy to eradicate H. pylori, and 9 of these patients had further ulcer complications. It appears, however, that four of the nine patients were reinfected with H. pylori, and an additional two patients took other nonsteroidal antiinflammatory drugs. If these 6 patients are excluded from the analysis, is there still a statistically significant difference (3 of 61 vs. 1 of 62 patients) in the recurrence of ulcer complications between the two treatment groups? If not, then the findings of Lai et al. are in keeping with the data published by Chan et al.,2 who reported that eradication of H. pylori is equivalent to treatment with omeprazole in preventing recurrent ulcer complications in patients with long-term low-dose aspirin use.

Laurence P. Maiden, M.B., B.S.
Adam W. Harris, M.D.
Kent and Sussex Hospital, Tunbridge Wells TN4 8AT, United Kingdom
lpmaiden@doctors.net.uk

2 References

1. 1

   Lai KC, Lam SK, Chu KM, et al. Lansoprazole for the prevention of recurrences of ulcer complications from long-term low-dose aspirin use. N Engl J Med 2002;346:2033-2038
   Full Text | Web of Science | Medline

2. 2

   Chan FKL, Chung SCS, Suen BY, et al. Preventing recurrent upper gastrointestinal bleeding in patients with Helicobacter pylori infection who are taking low-dose aspirin or naproxen. N Engl J Med 2001;344:967-973
   Full Text | Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: We found in our study that 14.8 percent of patients receiving placebo had a recurrence of ulcer complications. This high rate may have resulted in part from reinfection with H. pylori or a recrudescence of the original infection. Relapse of ulcer in our patients with persistent H. pylori infection confirms that such infection is also important in the pathogenesis of aspirin-related peptic ulcers.1 Despite this fact, it may be inappropriate to exclude these patients from the analysis, as Drs. Maiden and Harris suggest. Our patients had reinfection or recrudescence despite apparent initial eradication of H. pylori. Failed eradication or recrudescence of the H. pylori infection is not uncommon in clinical practice. Moreover, it is unknown whether frequent monitoring for relapse of H. pylori can be helpful in further reducing the risk of recurrent ulcer complications. Indeed, two of the four patients with recurrence of H. pylori had only a positive urea breath test (with negative results on both histologic analysis and urease testing of a biopsy specimen) when recurrent ulcer complications developed. Initial H. pylori eradication is not sufficient to prevent relapse of ulcer complications in patients receiving low-dose aspirin. To reflect real-life clinical practice, patients with a relapse of H. pylori infection should be included in the analysis.

On the other hand, only a small proportion of patients had a recurrence of ulcer when a proton-pump inhibitor was added to the regimen. Besides being useful in patients in whom H. pylori has been eradicated, it is very likely that a proton-pump inhibitor is useful in patients with a relapse of H. pylori infection (or even in those in whom an initial attempt at eradication has failed).

Kam Chuen Lai, M.R.C.P.
Wai Mo Hui, M.D.
Shiu Kum Lam, M.D.
Queen Mary Hospital, Hong Kong, China
kclai@hku.hk

1 References

1. 1

   Lanas A, Fuentes J, Benito R, Serrano P, Bajador E, Sainz R. Helicobacter pylori increases the risk of upper gastrointestinal bleeding in patients taking low-dose aspirin. Aliment Pharmacol Ther 2002;16:779-786
   CrossRef | Web of Science | Medline

Citing Articles (2)

Citing Articles

1. 1

   K. Haruma, M. Ito. (2003) Review article: clinical significance of mucosal-protective agents: acid, inflammation, carcinogenesis and rebamipide. Alimentary Pharmacology and Therapeutics 18:s1, 153-159
   CrossRef

2. 2

   (2003) Current Awareness: Pharmacoepidemiology and Drug Safety. Pharmacoepidemiology and Drug Safety 12:3, 253-268
   CrossRef