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In a phase III, prospective, industry-supported trial, investigators examined the safety and efficacy of treatment with a proton-pump inhibitor (PPI) plus aspirin to prevent progression of Barrett esophagus.
Over 2500 patients with Barrett esophagus were randomized to treatment with low-dose (20 mg once daily) or high-dose (40 mg twice daily) esomeprazole with or without full-dose, once-daily aspirin. The composite study endpoint was all-cause mortality or progression of Barrett esophagus to either high-grade dysplasia or cancer. Median follow-up was 9 years. Results were as follows:
High-dose PPI was superior to low-dose PPI in delaying time to the composite endpoint.
Aspirin use was superior to nonuse when NSAID users were censored from the analysis.
The combination of high-dose PPI and daily aspirin had the strongest protective effect.
Serious adverse events were rare (1%).
Jankowski JAZ et al. Esomeprazole and aspirin in Barrett's oesophagus (AspECT): A randomised factorial trial. Lancet 2018 Aug 4; 392:400. (https://doi.org/10.1016/S0140-6736(18)31388-6)
Hvid-Jensen F and Drewes AM.Should aspirin and PPIs be recommended for patients with Barrett's oesophagus? Lancet 2018 Aug 4; 392:362. (https://doi.org/10.1016/S0140-6736(18)31618-0)
Comment
This is a very important study that should change practice. While both PPIs and aspirin have proven adverse side effects, their protective effects in this study population outweigh those risks and make it very reasonable to put patients with well-established Barrett esophagus on combined PPI and aspirin therapy. The need for a high-dose PPI could be greater in patients with longer segments of Barrett esophagus (due to poor esophageal motility and increased acid exposure), but that cannot be determined from this study. I will encourage my patients with Barrett esophagus to take this combination regimen but will also look forward to further studies that examine which subgroups might be managed with lower doses of PPI, aspirin, or both.