Limmer S, Ittel T H, Wietholtz H
Klinikum Darmstadt, Medizinische Klinik II, 64283 Darmstadt, Germany.
Z Gastroenterol. 2003 Aug;41(8):719-28. doi: 10.1055/s-2003-41208.
Based on current references four clinical scenarios were discussed and different management strategies were compared for secondary and primary prophylaxis of ulcer or peptic ulcer bleeding under continuous therapy with non-steroidal antiinflammatory drugs (NSAID) or low-dose-aspirin, for H.pylori-positive and H.pylori-negative patients. Used as secondary prophylaxis eradication alone is insufficient in preventing recurrent peptic ulcer or recurrent ulcer bleeding for H.pylori-positive patients who continue to take unselective NSAIDs. Maintenance therapy with PPIs or switching from nonselective NSAID to COX-2-inhibitors is required after eradication of H.pylori or primary H.pylori-negative patients. Further evaluation is needed of what kind of secondary prophylaxis - maintenance therapy with PPI or switching to COX-2-inhibitor - is more (cost-)effective. It is sufficient to use eradication of H.pylori alone as secondary prophylaxis in preventing recurrent peptic ulcer or recurrent ulcer bleeding for H.pylori-positive patients, who continue to take low-dose-aspirin. Maintenance therapy with PPI is not generally required. However it can be considered for patients with increased risk for gastrointestinal complications (previous history of peptic ulcer, age over 65 years, concomitant use of corticosteroids, anticoagulants or individual NSAID with higher risk for gastrointestinal complications, serious cardiovascular disease). Switching from low-dose-aspirin to clopidogrel is not required. Used as primary prophylaxis in preventing peptic ulcer or ulcer bleeding before starting long-term therapy with NSAIDs, COX-2-inhibitors or unselective NSAIDs concomitant with PPIs are recommended for patients with increased risk for gastrointestinal complications. Patients starting long-term therapy with unselective NSAIDs should be screened for H.pylori and eradicated. There are no valid data supporting screening for H.pylori and eradication for patients starting long-term therapy with low-dose-aspirin. Further studies are needed to evaluate a possible benefit for patients with increased risk for gastrointestinal complications.
基于当前参考文献，讨论了四种临床情况，并比较了在非甾体抗炎药（NSAID）或低剂量阿司匹林持续治疗下，针对幽门螺杆菌阳性和阴性患者，溃疡或消化性溃疡出血的二级预防和一级预防的不同管理策略。单独使用根除疗法作为二级预防，对于继续服用非选择性NSAID的幽门螺杆菌阳性患者预防复发性消化性溃疡或复发性溃疡出血是不够的。在根除幽门螺杆菌后或原发性幽门螺杆菌阴性患者中，需要使用质子泵抑制剂（PPI）进行维持治疗或从非选择性NSAID转换为COX-2抑制剂。需要进一步评估哪种二级预防——PPI维持治疗或转换为COX-2抑制剂——更具（成本）效益。对于继续服用低剂量阿司匹林的幽门螺杆菌阳性患者，单独使用根除幽门螺杆菌作为二级预防来预防复发性消化性溃疡或复发性溃疡出血就足够了。一般不需要PPI维持治疗。然而，对于胃肠道并发症风险增加的患者（有消化性溃疡病史、年龄超过65岁、同时使用皮质类固醇、抗凝剂或具有较高胃肠道并发症风险的个别NSAID、严重心血管疾病）可以考虑使用。不需要从低剂量阿司匹林转换为氯吡格雷。在开始使用NSAID、COX-2抑制剂或与PPI联合使用的非选择性NSAID进行长期治疗之前，作为预防消化性溃疡或溃疡出血的一级预防，建议对胃肠道并发症风险增加的患者使用COX-2抑制剂。开始使用非选择性NSAID进行长期治疗的患者应筛查幽门螺杆菌并进行根除。没有有效数据支持对开始使用低剂量阿司匹林进行长期治疗的患者进行幽门螺杆菌筛查和根除。需要进一步研究来评估对胃肠道并发症风险增加的患者可能的益处。
