Comparison of rectal indomethacin, diclofenac, and naproxen for the prevention of post endoscopic retrograde cholangiopancreatography pancreatitis

Alizadeh, Amir Houshang Mohammad; Abbasinazari, Mohammad; Hatami, Behzad; Abdi, Saeed; Ahmadpour, Fatemeh; Dabir, Shideh; Nematollahi, Aida; Fatehi, Samira; Pourhoseingholi, Mohammad Amin

doi:10.1097/meg.0000000000000787

Cited by 23 publications

(19 citation statements)

References 14 publications

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“… 25 Furthermore, among the NSAIDs, diclofenac was acted better than indomethacin 24 and naproxen. 26 Howbeit some controversies have existed about the superiority of diclofenac against other NSAIDs. 25 - 27 We also previously in a double-blind RCT reported that single suppository dose of 500 mg naproxen, as another member of NSAIDs, immediately before ERCP decreased the rate of PEP.…”

Section: Discussionmentioning

confidence: 99%

“… 26 Howbeit some controversies have existed about the superiority of diclofenac against other NSAIDs. 25 - 27 We also previously in a double-blind RCT reported that single suppository dose of 500 mg naproxen, as another member of NSAIDs, immediately before ERCP decreased the rate of PEP. 28 Based on all of the above mentioned shreds of evidence, it seems that rectal NSAIDs are effective and safe in the prevention of PEP in all levels of risk.…”

Section: Discussionmentioning

confidence: 99%

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Naproxen, isosorbide dinitrate and co-administration cannot prevent post-endoscopic retrograde cholangiopancreatography pancreatitis: Randomized controlled trial

Mansour-Ghanaei¹,

Joukar

Khalesi³

et al. 2020

Ann Hepatobiliary Pancreat Surg

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Backgrounds/Aims: Acute pancreatitis is the most widespread complication of endoscopic retrograde cholangiopancreatography. Here, we investigated the efficacy of rectal suppository naproxen, sublingual isosorbide dinitrate and their co-administration in the prevention of post-ERCP pancreatitis. Methods: This double-blind randomized clinical trial carried out from June 2015 to February 2016 at the Gastrointestinal and Liver Diseases Research Center in Rasht, Iran. A total of 585 patients were selected from candidates for diagnostic or therapeutic ERCP by using the simple sampling method. Patients divided into three groups. Group A received 500 mg naproxen, group B took 5 mg isosorbide dinitrate, and group C was co-administrated both agents before ERCP. The primary outcome measure was the development of pancreatitis onset of pain in the upper abdomen and increase of serum amylase activity more than 3 times over the upper normal limit (60-100 IU/L) within first the 24 h post-ERCP. Results: Totally, 80 patients developed PEP included 29 (4.9%), 24 (4.1%), and 27 (4.6%) patients in groups A, B, and C, respectively (p=0.845). Longer ERCP time (p=0.041), using diazepam (p=0.033), a higher number of pancreatic ducts cannulation (p＜0.001), pancreatic duct injection (p=0.013), and using pancreatic stent (p=0.004) were the predisposing factors for PEP. Conclusions: Our findings indicated that prophylactic naproxen suppository or isosorbide dinitrate sublingually or co-administration had no significant difference in the prevention and severity of PEP, however, enhancing the endoscopist's skills can be effective. Departments and educational hospitals should develop their assessment and quality assurance measures for the training of fellows' not only technical training but also an understanding of the diagnostic and therapeutic roles of the procedure.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Naproxen, isosorbide dinitrate and co-administration cannot prevent post-endoscopic retrograde cholangiopancreatography pancreatitis: Randomized controlled trial

Mansour-Ghanaei¹,

Joukar

Khalesi³

et al. 2020

Ann Hepatobiliary Pancreat Surg

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“…To date, only one clinical trial 42 has directly compared the efficiency of rectal indomethacin and diclofenac in the prevention of PEP among unselected patients. However, in that study, PEP was defined as a more than 300% increase in amylase and lipase levels compared with the baseline value, with a less than three‐fold increase in the upper normal limit levels, 24 h after the procedure, accompanied by abdominal pain, leading to prolonged hospitalization 42 . This definition is not in conformance with the consensus criteria of acute pancreatitis and differs from the standard definition used in the RCTs included in our meta‐analysis.…”

Section: Discussionmentioning

confidence: 99%

Rectal indomethacin and diclofenac are equally efficient in preventing pancreatitis following endoscopic retrograde cholangiopancreatography in average‐risk patients

Shen

et al. 2021

JGH Open

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Rectal indomethacin and diclofenac are promising drugs for prevention of post‐endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). However, their prophylactic effect on PEP in average‐risk patients remains controversial. We performed a systematic review and meta‐analysis to assess the efficacy and safety of rectal indomethacin and diclofenac in average‐risk patients, and to indirectly compare the prophylactic effect of the two drugs. A comprehensive search of the PubMed, EMBASE, and Cochrane Library databases was performed to identify randomized controlled trials (RCTs) on rectal indomethacin or diclofenac for prophylaxis against PEP. Fixed‐ and random‐effects models weighted by the Mantel–Haenszel method were used for direct comparisons. The adjusted indirect treatment comparison method was used to indirectly compare the efficacy of indomethacin and diclofenac. A total of 10 RCTs, including 2928 patients, met our inclusion criteria. No significant publication bias was identified. Pooled estimates showed that rectal indomethacin and diclofenac were associated with a significant reduction in the overall risk of PEP compared with control intervention [relative risk (RR) = 0.62; 95% confidence interval (CI): 0.46–0.83] in average‐risk patients. Subgroup analyses showed that both rectal indomethacin (RR = 0.67; 95% CI: 0.49–0.94) and diclofenac (RR = 0.42; 95% CI: 0.23–0.75) were effective in the prevention of PEP. Indirect comparison showed no significant difference between the effectiveness of the two drugs in the prevention of PEP (RR = 1.607; 95% CI: 0.824–3.136). The updated meta‐analysis suggests that both drugs provide equivalent protection against PEP in average‐risk patients.

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“…The study conducted by Levenick et al in patients at average risk of ERCP showed that rectal NSAIDs may not have prophylactic benefits in average-risk patients [13]. Among NSAIDs, diclofenac and indomethacin are more effective than naproxen in PEP prophylaxis [15]. The administration route is also significant as NSAIDs administered via the rectal route effectively prevents PEP [7,9,11,12].…”

Section: Non-steroidal Anti-inflammatory Drugs (Nsaids)mentioning

confidence: 99%

Pharmacological Prevention of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis: Where Do We Stand Now?

Ahmad

Okam

Torrilus

et al. 2020

Cureus

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Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is the most frequently occurring complication of endoscopic retrograde cholangiopancreatography (ERCP). PEP is associated with significant morbidity and mortality; that is why the prevention of PEP is essential. Pharmacoprevention holds a central position in PEP prophylaxis. The current literature explores the efficacy of various pharmacological agents in preventing PEP, their routes of administration, and the correct administration timing. Data was collected on PubMed using regular keywords, the latter yielded 2077 papers. After applying inclusion and exclusion criteria, 218 papers were selected and screened and 28 studies were finally chosen after the removal of duplicate and irrelevant studies. The selected 28 articles comprised 25 randomized clinical trials and three systematic reviews. The study concludes that rectal non-steroidal anti-inflammatory drugs (NSAIDs) administered before ERCP are effective in preventing PEP in high-risk patients. The efficacy of rectal NSAIDs in low to medium risk group is not well established. A combination of rectal NSAIDs and intravenous hydration provides improved prophylaxis against PEP in high-risk patients than NSAIDs alone. Nafamostat, sublingual nitrates, and intravenous hydration are potential alternatives in patients with contraindications to NSAIDs.

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Comparison of rectal indomethacin, diclofenac, and naproxen for the prevention of post endoscopic retrograde cholangiopancreatography pancreatitis

Abstract: Diclofenac and indomethacin patient groups had a lower incidence of PEP than the naproxen group.

Cited by 23 publications

References 14 publications

Naproxen, isosorbide dinitrate and co-administration cannot prevent post-endoscopic retrograde cholangiopancreatography pancreatitis: Randomized controlled trial

Naproxen, isosorbide dinitrate and co-administration cannot prevent post-endoscopic retrograde cholangiopancreatography pancreatitis: Randomized controlled trial

Rectal indomethacin and diclofenac are equally efficient in preventing pancreatitis following endoscopic retrograde cholangiopancreatography in average‐risk patients

Pharmacological Prevention of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis: Where Do We Stand Now?

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