Upper gastrointestinal bleeding (UGIB) remains a major problem worldwide. Over time the management issues have changed and a paradigm shift occurred when it became clearly established that eradication of Helicobacter pylori would ”cure” peptic ulcers, including the elimination of new ulcers, recurrent ulcers, and ulcer complications. The subsequent recognition that H. pylori infections increased the risk of complications from nonsteroidal anti-inflammatory drugs (NSAIDs) led to the recommendation to test NSAID and aspirin users for H. pylori, and to eradicate the infection whenever it is found. Unfortunately, eradication of H. pylori is no longer straightforward, as clinicians are facing the increasing challenge of resistant strains. Moreover, eradication of H. pylori alone will not solve the problem of NSAID ulcer complications because NSAIDs themselves increase the risk of UGIB. Unresolved issues include identification of the circumstances in which particular traditional NSAIDs or cyclo-oxygenase-2 (COX-2)-selective inhibitors are preferred, and the actual role for gastroprotective co-therapy.
Although there are many studies on gastroprotective therapies, their clinical effectiveness remains unclear. This is due, in part, because (with few exceptions) pharmaceutical company-sponsored trials have used surrogate markers instead of clinically relevant outcome trials in high-risk patients. When one searches for data, one finds that pharmaceutical company-sponsored consensus statements appear to outnumber relevant clinical trials. The available data have also focused on relative instead of absolute risk or risk reduction, and are therefore of limited use for clinical decision making. Clinical decision making has been further complicated by the recent realization that the benefits obtained from NSAID use may be offset by an increase in cardiovascular complications (e. g. myocardial infarctions). This review highlights new data that address these current issues. Five recent papers have been selected for more detailed analyses [1]
[2]
[3]
[4]
[5].
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