FPIN's Clinical Inquiries

H. pylori Screening Before Initiation of Long-term NSAIDs


Am Fam Physician. 2019 Jun 15;99(12):783-784.

Clinical Question

Should clinicians perform laboratory screening for and eradicate Helicobacter pylori in patients before initiating long-term therapy with nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce the risk of peptic ulcer disease?

Evidence-Based Answer

Physicians should perform laboratory screening for and eradicate H. pylori before initiating long-term NSAID therapy in NSAID-naive patients to reduce the risk of peptic ulcer disease. (Strength of Recommendation [SOR]: A, based on meta-analyses of randomized controlled trials [RCTs].) Physicians should screen for and eradicate H. pylori before initiating long-term NSAID therapy in patients with a history of peptic ulcers. (SOR: B, based on a meta-analysis of case-controlled studies.)

Evidence Summary

A 2012 meta-analysis of seven RCTs (N = 1,254) examined whether eradication therapy for H. pylori infection decreased the incidence of peptic ulcer disease in adults receiving long-term NSAID therapy.1 Western and Asian populations were represented. The primary end point was the development of peptic ulcer disease during follow-up. Most participants were female (61% to 81%). Peptic ulcer disease developed in 6.4% of participants who underwent eradication therapy compared with 11.8% of those who did not (odds ratio [OR] = 0.50; 95% CI, 0.36 to 0.74; number needed to treat [NNT] = 18). In a subanalysis of three studies of NSAID-naive patients (n = 532), a significant risk reduction was noted in the eradication group: 10 of 262 participants (3.8%) in the eradication group developed a peptic ulcer vs. 37 of 270 (13.7%) in the noneradication group (OR = 0.26; 95% CI, 0.14 to 0.49; NNT = 10). In a subanalysis of participants receiving long-term NSAID therapy (n = 822), there was no statistical difference between the eradication and noneradication groups (OR = 0.74; 95% CI, 0.46 to 1.20).

A 2002 meta-analysis of 16 case-control or cross-sectional studies of adults (N = 1,625) linked H. pylori infection to development of peptic ulcer

Address correspondence to Malissa Talbert, MD, at Malissa.Talbert@erlanger.org. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.


show all references

1. Tang CL, Ye F, Liu W, Pan XL, Qian J, Zhang GX. Eradication of Helicobacter pylori infection reduces the incidence of peptic ulcer disease in patients using nonsteroidal anti-inflammatory drugs: a meta-analysis. Helicobacter. 2012;17(4):286–296....

2. Huang JQ, Sridhar S, Hunt RH. Role of Helicobacter pylori infection and non-steroidal anti-inflammatory drugs in peptic-ulcer disease: a meta-analysis. Lancet. 2002;359(9300):14–22.

3. Chey WD, Leontiadis GI, Howden CW, Moss SF. ACG clinical guideline: treatment of Helicobacter pylori infection [published correction appears in Am J Gastroenterol. 2018;113(7):1102]. Am J Gastroenterol. 2017;112(2):212–239.

4. Satoh K, Yoshino J, Akamatsu T, et al. Evidence-based clinical practice guidelines for peptic ulcer disease 2015. J Gastroenterol. 2016;51(3):177–194.

5. Malfertheiner P, Megraud F, O'Morain CA, et al.; European Helicobacter and Microbiota Study Group and Consensus Panel. Management of Helicobacter pylori infection–the Maastricht V/Florence Consensus Report. Gut. 2017;66(1):6–30.

Clinical Inquiries provides answers to questions submitted by practicing family physicians to the Family Physicians Inquiries Network (FPIN). Members of the network select questions based on their relevance to family medicine. Answers are drawn from an approved set of evidence-based resources and undergo peer review. The strength of recommendations and the level of evidence for individual studies are rated using criteria developed by the Evidence-Based Medicine Working Group (http://www.cebm.net).

The complete database of evidence-based questions and answers is copyrighted by FPIN. If interested in submitting questions or writing answers for this series, go to http://www.fpin.org or e-mail: questions@fpin.org.

This series is coordinated by John E. Delzell Jr., MD, MSPH, Associate Medical Editor.

A collection of FPIN's Clinical Inquiries published in AFP is available at https://www.aafp.org/afp/fpin.



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