Efficacy and safety of rectal nonsteroidal anti-inflammatory drugs for prophylaxis against post-ERCP pancreatitis: a systematic review and meta-analysis

Abstract

Rectal nonsteroidal anti-inflammatory drugs (NSAIDs) are not commonly used clinically for preventing post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. To evaluate the efficacy and safety of NSAIDs for post-ERCP prophylaxis, we systematically reviewed sixteen randomized controlled trials (involving 6458 patients) that compared rectal NSAIDs with placebo or no treatment for post-ERCP pancreatitis prophylaxis updated to August 2016. GRADE framework was used to assess the quality of evidence. There was “high quality” evidence that rectal NSAIDs were associated with significant reduction in the risk of overall post-ERCP pancreatitis (RR, 0.55; 95% CI, 0.42–0.71). Subgroup analyses demonstrated that diclofenac (RR, 0.41; 95% CI, 0.19–0.90) was probably superior to indomethacin (RR, 0.58; 95% CI, 0.45–0.75), post-ERCP administration (RR, 0.46; 95% CI, 0.24–0.89) was probably superior to pre-ERCP (RR, 0.53; 95% CI, 0.42–0.67), and that mixed-risk population received more benefits (RR, 0.54; 95% CI, 0.33–0.88) than average-risk population (RR, 0.60; 95% CI, 0.41–0.88), but less than high-risk population (RR, 0.41; 95% CI, 0.19–0.91). Moreover, “high quality” evidence showed that rectal NSAIDs were safe when given as a standard dose (RR = 0.80; 95% CI, 0.47–1.36). In conclusion, this meta-analysis revealed that rectal NSAIDs are effective and safe in the prevention of post-ERCP pancreatitis in populations with all levels of risk.

What is impact of nonsteroidal anti-inflammatory drugs in the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: a meta-analysis of randomized controlled trials

“…The results showed that NSAIDs administered pre-ERCP may be more effective than those administered post-ERCP. This result is similar to the conclusion of a meta-analysis in 2017 that incorporates 16 studies [ 40 ]. However, there are different voices on the ideal time of administration [ 43 – 46 ].…”

“…No study has compared rectal indomethacin and diclofenac in a head-to-head trial to see if there is any difference in the efficacy between these 2 agents. Previous meta-analysis showed that diclofenac was more effective than other NSAIDs in reducing the incidence of PEP [ 40 , 41 ]. However, one of the studies described only the rectal route of administration [ 40 ], and the other included the study included the rectal 、intravous、intramuscular and oral administration [ 41 ].…”

Does rectal diclofenac reduce post-ERCP pancreatitis? A district general hospital experience

“…These findings are also supported by a meta-analysis performed by Puig et al 20. Contrary to this, a more recent meta-analysis performed by Hou et al 21 showed that rectal diclofenac is likely to be more superior than indomethacin and post-ERCP is probably more superior to pre-ERCP. They showed a reduction in the incidence of PEP and a reduction in the severity of PEP.…”

Systematic Review of Most Common Causes of Acute Pancreatitis

“…Oddi sphincter manometry procedures are associated with BP in 25% of cases. The routine using 100mg of indomethacin or diclofenac rectal route, immediately before or after ERCP is indicated routine and significantly reduces the risk of this complication [43][44][45].…”