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Aspirin + high-dose PPI prevents death and progression in patients with Barrett's esophagus (AspECT)
Clinical Question
Does aspirin plus a proton pump inhibitor prevent death, malignant transformation, or histologic progression in patients with Barrett's esophagus?
Bottom line
In this study, patients with Barrett's esophagus were less likely to die or develop esophageal cancer or high-grade dysplasia if they took high-dose esomeprazole alone or in combination with aspirin. 1b
Reference
Study design: Randomized controlled trial (single-blinded)
Funding: Industry + govt
Setting: Outpatient (specialty)
Synopsis
These authors recruited 2557 patients with at least 1 cm of Barrett's esophagus to participate in a study with a randomized factorial design that included low- or high-dose esomeprazole (Nexium; 20 mg daily or 40 mg twice daily, respectively) with or without aspirin (300 mg in the UK or 325 mg in Canada). The researchers followed the patients for up to 10 years (wow!) in person or by telephone. In the even years after recruitment, they also performed endoscopy on the patients. Although the patients knew what treatment they received, the pathologists who reviewed the biopsy material were unaware of the patients' treatment allocation. The authors used a composite outcome (I really dislike these) of all-cause mortality, esophageal adenocarcinoma, or high-grade dysplasia. After a median of 8.9 years, 313 total patients experienced the composite outcome. Patients who took high-dose esomeprazole had fewer events (11%) than those who took the low dose (14%; number needed to treat [NNT] = 36; 95% CI 19 - 406). The combination of aspirin plus esomeprazole was more effective: 9% of patients taking aspirin plus high-dose esomeprazole compared with 14% of those taking aspirin plus low-dose esomeprazole (NNT = 20;12 - 67) experienced the primary outcome. Aspirin alone was ineffective in preventing the primary outcome. A total of 718 of the patients experienced at least one adverse event (28%), 61 of whom experienced a serious event (2% of the total pool, 8% of adverse events), but the differences among the treatment groups were similar.
Reviewer
Henry C. Barry, MD, MS
Professor
Michigan State University
East Lansing, MI
Comments
Nice study. But it is yet another situation where the MD is trying to « sell » a patient on the earthly pleasures of reducing their absolute risk of an outcome by 3 or 4 %.
I wonder how many patients would decline treatment if they knew there was only a one in 35 chance of the medication helping them over the next 10 years
I have a patient who had Barrett's esophagus and has progressed to ca. It would possibly have been helpful for her.
It is difficult/impossible to compare 'serious adverse event' significances; a Hemorrhagic CVA may seem less acceptable than, say, an ulcer. ASA may reduce embolic CVAs for example , but increase hemorrhagic ones. Take your pick, but don't pretend there is an objective choice available.
Aspirin+high dose PPI prevent death and progression in patie
There is high chance for patient with Barrett's esophagus to progressed to esophageal Cancer. It great to know that Aspirin + high dose PPI prevent death and progression in patient with Barrett's esophagus.I have couple of patients who can get benefit from this.
It is very valuable information. Progression of Barrett's esophagus to cancer is common finding . So Aspirin +high dose PPI can prevent progression. I can use this to treatment patient diagnose with Barrett's esophagus.
Many patients with GERD develop Barretts esophagus over the years and they just complain of the reflux symptoms at the beginning, initiating Aspirin with the PPI could be helpful to prevent the dysplastic esophageal changes on the long term instead of the PPI alone.
I had no idea that ASA was being used for this reason. Very interesting read
Excellent
good poem