Low-dose aspirin and peptic ulcers

Low-dose aspirin use increases the risk of peptic ulceration. About 1 in 10 patients taking long-term aspirin have an ulcer at endoscopy, though most do not have symptoms. Aspirin increases the risk of a bleeding ulcer and erosions; this effect is dose dependent and is not reduced by using enteric-coated aspirin. A history of peptic ulcer disease, current Helicobacter pylori infection or concurrent nonsteroidal anti-inflammatory drug (NSAID) use markedly increases this risk.

Primary prophylaxis with a proton pump inhibitor (PPI) reduces the risk of peptic ulceration and the risk of bleedingScheiman, 2011. Primary prophylaxis with a PPI is generally reserved for high-risk patients (see Risk factors for NSAID-induced ulcers). For patients known to have had peptic ulcer disease, H. pylori should be sought and treated if present, before starting aspirin.

For patients who develop a bleeding peptic ulcer while taking aspirin but still require antiplatelet therapy, PPI use (and H. pylori eradication if infection is present) reduces the risk of recurrent ulcer bleeding. Testing for and treating H. pylori infection in these patients is evidence-based and recommended by international guidelines. Data suggest that recurrent bleeding is less likely with continued aspirin use and PPI prophylaxis than with a switch from aspirin to clopidogrelScheiman, 2005.