Helicobacter pylori eradication and aspirin: a puzzle yet to be solved – Author's reply

We thank Luigi Gatta and colleagues for their comments on our study.1Hawkey C Avery A Coupland CAC et al.Helicobacter pylori eradication for primary prevention of peptic ulcer bleeding in older patients prescribed aspirin in primary care (HEAT): a randomised, double-blind, placebo-controlled trial.Lancet. 2022; 400: 1597-1606Summary Full Text Full Text PDF PubMed Scopus (5) Google Scholar At the time that the Helicobacter Eradication Aspirin Trial was devised, a 7-day course of clarithromycin-based triple therapy was recommended in the European Maastricht consensus report2Malfertheiner P Megraud F O'Morain C et al.Current concepts in the management of Helicobacter pylori infection—the Maastricht 2-2000 consensus report.Gut. 2007; 56: 772-781Crossref PubMed Scopus (1776) Google Scholar and American College of Gastroenterology guidelines.3Chey WD Wong BC American College of Gastroenterology guideline on the management of Helicobacter pylori infection.Am J Gastroenterol. 2007; 192: 1808-1825Crossref Scopus (1065) Google Scholar This regimen achieved a H pylori eradication rate of 91·3% in the pilot studies we conducted on our proposed patient population.4Dumbleton JS Avery AJ Coupland C et al.The Helicobacter Aspirin Eradication Trial (HEAT): a large simple randomised controlled trial using novel methodology in primary care.EBioMedicine. 2015; 2: 1200-1204Summary Full Text Full Text PDF PubMed Google Scholar The eradication rate was similar in the full-size study (90·7%), against a background of increasing drug resistance globally. One possibility worth investigating is that aspirin, which can dissipate the mucus layer in the stomach,5Goddard PJ Kao Y-C Lichtenberger LM Luminal surface hydrophobicity of canine gastric mucosa is dependent on a surface mucous gel.Gastroenterology. 1990; 98: 361-370Summary Full Text PDF PubMed Scopus (93) Google Scholar might increase exposure of H pylori to antibiotics and result in more effective elimination. We disagree with the suggestion that all patients should have undergone retesting. The abiding principle that enables us to conduct large studies in primary care, for both funding and logistical reasons, is simplicity. Arguably, by reflecting the clinical realities of routine care settings, in which resource utilisation is an issue, this feature of the study also adds to the authenticity and applicability of the findings. I report research funding from the Cancer Research UK AsCaP Catalyst Collaboration (A24991) and from the UK National Institute for Health and Care Research Health Technology Assessment programme for the ALL-HEART (11/36/41) and ATTACK (16/31/127) studies. Helicobacter pylori eradication and aspirin: a puzzle yet to be solvedWe read with great interest the Article by Chris Hawkey and colleagues1 on the Helicobacter Eradication Aspirin Trial (HEAT). The authors should be commended for performing such a complex trial. Although the trial was conceived to evaluate the role of Helicobacter pylori eradication in older patients (aged ≥60 years) prescribed aspirin, the study was not planned to verify eradication. A breath retest was randomly performed in only 10% of patients, reporting H pylori eradication in 146 (90·7%) of 161 patients receiving active eradication therapy. Full-Text PDF Helicobacter pylori eradication for primary prevention of peptic ulcer bleeding in older patients prescribed aspirin in primary care (HEAT): a randomised, double-blind, placebo-controlled trialH pylori eradication protects against aspirin-associated peptic ulcer bleeding, but this might not be sustained in the long term. Full-Text PDF Open Access