To the Editor:
The editorial by Lanas y Ferrández1 on the use of gastric protection in patients on low-dose aspirin therapy that recently appeared in the Revista is very interesting. The significant morbidity from cardiovascular disease in Western societies, the fact that aspirin has been shown to be effective in the prevention of coronary or cerebrovascular events, together with the authors´ experience on this subject makes the article of great interest. Nevertheless, we would like to make some comments on the contents of this editorial. We believe that until more studies are done, we must take into account other risk factors for the develop of complications in patients on aspirin therapy who have a history of ulcerative disease or digestive hemorrhage, who are taking non-steroidal anti-inflammatory medication (NSAIDs) in conjunction with aspirin, and who are infected with Helicobacter pylori. Age of 60 years or greater and corticoid or anticoagulant therapy are risk factors that must be taken into account when adding a protective agent for the gastric mucosa, as is advised in patients treated with classic NSAIDs.2
On the other hand, although we agree with the recommendation to use proton pump inhibitors as preventative measure for patients on chronic aspirin therapy, we do not think it accurate to conclude that the eradication of H. pylori is recommended in these patients. Studies on the subjects on the use of NSAIDs at the usual doses are controversial, and it has even been suggested that H. pylori may have a protective effect against lesions caused by NSAIDs. In the recommendations of the Conferencia Española de Consenso3 the inadvisability of eradicating the bacteria in asymptomatic patients taking NSAIDs was mentioned, and it was also recommended that in the presence of a concomitant history of ulcer, the bacteria should be protected with a proton pump inhibitor, and to wait until NSAIDs are no longer being taken before eradicating the bacteria. As noted in the editorial, there are few current studies on the use of low-dose aspirin, with few patients, short followup periods; and some of which are only abstracts and report conflicting results.1,4,5 Many questions are raised by accepting the recommendation to eliminate H. pylori in these patients: would we have to know if a patient is infected before prescribing low-dose aspirin? Should we only check if the patient has a history of ulcers? What diagnostic tests would have to be performed a breath test, serology testing for the bacteria, or endoscopy, biopsy, and urine tests? Should the eradication of the bacteria be confirmed later? Therefore, we think that it is premature and excessive to advise this course given current contraindications and without it being established which patients are involved, and when, and how it should be carried out.