Z Gastroenterol 2003; 41(8): 719-728
DOI: 10.1055/s-2003-41208
Übersicht
© Karl Demeter Verlag im Georg Thieme Verlag Stuttgart · New York

Sekundär- und Primärprophylaxe der ASS-/NSAR-Gastropathie: Eine Übersicht anhand vier klinischer Szenarien

Secondary and Primary Prophylaxis of Gastropathy Associated with Nonsteroidal Antiinflammatory Drugs or Low-Dose-Aspirin: A Review Based on Four Clinical ScenariosS. Limmer1 , T. H. Ittel2 , H. Wietholtz1
  • 1Klinikum Darmstadt, Medizinische Klinik II, 64283 Darmstadt
  • 2Zentrum für Innere Medizin, Neurologie und Geriatrie, Klinikum der Hansestadt Stralsund, 18435 Stralsund
Further Information

Publication History

Manuskript-Eingang: 17. September 2002

Annahme nach Revision: 10. Februar 2003

Publication Date:
11 August 2003 (online)

Zusammenfassung

In vier klinischen Szenarien werden anhand der aktuellen Literatur die Möglichkeiten der Sekundär- und Primärprophylaxe eines Ulkus oder einer Ulkusblutung bei fortgesetzter Therapie mit unselektiven nichtsteroidalen Antirheumatika (NSAR) oder niedrig dosiertem ASS sowohl bei Helicobacter-positiven als auch -negativen Patienten verglichen.

Zur Sekundärprophylaxe eines Rezidivulkus oder Blutung reicht bei fortgesetzter unselektiver NSAR-Medikation für Helicobacter-infizierte Patienten eine alleinige Eradikation nicht aus, sondern nach der Eradikation ist eine begleitende Medikation mit Protonenpumpenblockern (PPI) oder die Umstellung von unselektiven NSAR auf einen selektiven COX-2-Inhibitor erforderlich. Auch für primär H.p.-negative Patienten ist zur Sekundärprophylaxe eine begleitende Medikation mit PPI oder die Umstellung auf einen selektiven COX-2-Inhibitor erforderlich. Welche der beiden Alternativen effektiver und kostengünstiger ist, muss durch weitere direkt vergleichende Studien geklärt werden. Zur Sekundärprophylaxe eines Rezidivulkus oder Blutung unter fortgesetzter Low-Dose-ASS-Therapie reicht bei H.p.-positiven eine alleinige Eradikation aus. Eine Fortsetzung der PPI-Therapie nach Eradikation ist nicht erforderlich, kann jedoch bei erhöhtem Risiko für gastrointestinale Komplikationen (Ulkusanamnese, begleitende Medikation mit Kortikosteroiden, Antikoagulanzien oder NSAR mit höherem relativen Risiko für gastrointestinale Komplikationen, Alter > 65 Jahre, schwere kardiovaskuläre Begleiterkrankungen) in Erwägung gezogen werden. Ein Umstellen von ASS auf das teurere Clopidogrel ist nicht gerechtfertigt.

Die Primärprophylaxe eines Ulkus oder einer Ulkusblutung ist vor Beginn einer Dauertherapie mit NSAR für Patienten mit erhöhtem Risiko für gastrointestinale Komplikationen (s. o.) sinnvoll. Sowohl die Gabe von COX-2-Inhibitoren als auch von unselektiven NSAR unter PPI-Schutz ist möglich, bei letzterer ist eine H.p.-Diagnostik und Eradikation bei H.p.-positivem Befund zu empfehlen. Es gibt keine validen Daten, die eine zwingende Überprüfung des Helicobacter-Status und ggf. anschließende Eradikation zur Primärprophylaxe vor Einleitung einer Low-Dose-ASS-Therapie fordern. Ob dies für Patienten mit erhöhtem Risiko für gastrointestinale Komplikationen zu empfehlen ist, müsste durch Studien validiert werden.

Abstract

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.

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Prof. Dr. med. H. Wietholtz

Direktor der Medizinischen Klinik II, Klinikum Darmstadt

Grafenstraße 9

64283 Darmstadt