Interaction between Helicobacter pylori infection, nonsteroidal anti-inflammatory drugs and/or low-dose aspirin use: Old question new insights

Table 1 Mechanisms of upper gastrointestinal injury with Helicobacter pylori infection, low dose aspirin and non steroidal anti-inflammatory drugs

Mechanism	LDA	NSAID	H. pylori
Prostaglandin/effect on COX enzyme	Selective and irreversible inhibition of COX-1	Inhibition of both isoforms of COX enzyme (COX-1 and 2)	Increase/up regulation COX-2
Gastric pH	Decrease	Decrease	Decrease or increase or no effect
PMN mediated gastric mucosa injury	Increase	Increase	Increase
Gastric mucosal flow	Decrease	Decrease	Increase
Gastric adaptation to LDA and NSAIDs			Reduce

Adapted from reference [5]. LDA: Low dose aspirin; NSAID: Non steroidal anti-inflammatory drugs; H. pylori: Helicobacter pylori; PMN: Polimorphonuclear cells; COX: Cicloxigenase.

Table 2 Summary of statements and recommendations of main international guidelines about Helicobacter pylori eradication in non steroidal anti-inflammatory drugs and low dose aspirin users

Statements and recommendations	Guideline/consensus	EL GR
H. pylori infection is a risk factor of PUD in NSAIDs and low dose ASA users	Maastricht IV Consensus	EL: 2a GR: B
	American Guideline
Eradication of H. pylori infection reduces the risk of complicated an uncomplicated gastroduodenal ulcers in NSAID and low dose ASA users	Maastricht IV Consensus	EL: 1b GR: A
In NSAIDs naïve users, H.pylori eradication is beneficial. It is mandatory in patients with a peptic ulcer history	Maastricht IV Consensus	EL: 1b GR: A
	II Asian-Pacific Guidelines	EL: 1a GR: A
	III Spanish Consensus	EL: weak GR: low
In chronic NSAIDs users with history of peptic ulcer, eradication alone is insufficient to prevent ulcer recurrence and/or bleeding. They require continued PPI treatment	American Guideline
	Maastricht IV Consensus	EL: 1b GR: A
In low dose ASA naïve users with peptic ulcer history, eradication of H. pylori infection is indicated	II Asian-Pacific Guidelines	EL: 1b GR: A
	Maastricht IV Consensus	EL: 2b GR: B
	II Asian-Pacific Guidelines	EL: 1b GR: B
In chronic low dose ASA users with a history of peptic ulcer, eradication of H. pylori infection is indicated	III Spanish Consensus	EL: weak GR: low
	American Guideline
	Maastricht IV Consensus	EL: 2b GR: B
	II Asian-Pacific Guidelines	EL: 1b GR: B
	III Spanish Consensus	EL: weak GR: low
	American Guideline
The long-term incidence of peptic ulcer bleeding is low in low dose ASA users after receiving eradication even in the absence of gastroprotective treatment	Maastricht IV Consensus	EL: 2b GR: B

EL: Evidence level; GR: Grade of recommendation; PUD: Peptic ulcer disease; ASA: Aspirin; NSAID: non steroidal anti-inflammatory drugs; H. pylori: Helicobacter pylori.