Although Helicobacter pylori is present in about one half of patients with peptic ulceration who use nonsteroidal anti-inflammatory drugs (NSAIDs), it is not known whether H. pylori infection increases the risk of peptic ulceration during NSAID therapy. Chan and colleagues evaluated whether H. pylori infection predisposes patients to NSAID–associated peptic ulceration and if eradication of the organism before initiation of NSAID therapy would protect patients from this complication.

Ninety-two patients with musculoskeletal disorders that required NSAID therapy participated in the eight-week study. All of the study subjects had H. pylori infection, but none had preexisting ulcers. None of the patients had previous exposure to NSAID therapy. Patients were randomly assigned to begin NSAID therapy immediately or to receive a one-week course of therapy to eradicate H. pylori before starting NSAID therapy. NSAID therapy consisted of 750 mg of naproxen daily in three divided doses. The H. pylori eradication regimen included bismuth subcitrate, tetracycline and metronidazole. Patients were monitored clinically and by repeat endoscopy after eight weeks of naproxen therapy. Pill counts were used to monitor compliance.

The two groups of patients were matched in terms of age, sex, severity of arthritis, smoking and drinking habits. Of the 45 patients who received H. pylori eradication therapy, 40 (89 percent) initially became free of infection. H. pylori persisted in all of the patients who did not receive eradication therapy. Twelve of the patients who did not receive eradication therapy developed peptic ulceration within eight weeks. Five of these patients had pain, and one had gastrointestinal bleeding. Peptic ulcers developed in three of the patients given eradication therapy. Two of these patients subsequently had failure of eradication. Thus, peptic ulcers developed in only one of the patients in whom H. pylori was eradicated before the start of NSAID therapy.

The authors conclude that eradication of H. pylori before the initiation of NSAID therapy reduced the eight-week cumulative rate of NSAID-induced ulcers by almost fourfold. They recommend serologic testing for H. pylori and eradication of the organism before NSAID therapy is initiated.