How to select patients and timing for rectal indomethacin to prevent post-ERCP pancreatitis: a systematic review and meta-analysis

Wan, Jianhua; Ren, Yuping; Zhu, Zhenhua; Xia, Liang; Lü, Nonghua

doi:10.1186/s12876-017-0599-4

Cited by 32 publications

(19 citation statements)

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“…Wan et al . showed that preoperative administration of indomethacin was better than postoperative administration [ 47 ], but in this study, the authors combined the intraoperative administration of Levenick et al and postoperative administration [ 15 ]. The studies of Inamdar et al and Sethi et al showed no difference between the preoperative and postoperative groups [ 45 , 46 ], but the above studies included eight and seven studies, respectively.…”

Section: Discussionmentioning

confidence: 99%

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

et al. 2018

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BackgroundRecently, although studies have investigated the role of NSAIDs in the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP), selection of the ideal drug, the time and route of its administration for the appropriate population remain controversial.MethodsA systematic search was done in sources including PubMed, Embase, Web of Science, the Cochrane Library Central, and ClinicalTrials.gov from from August 1, 1990 to August 1, 2017. Randomized controlled trials comparing the prophylactic use of NSAIDs versus a placebo were included. Statistical analysis was performed using the RevMan 5.3 software to assess the outcomes.ResultsA total of 21 randomized controlled trials were included in the meta-analysis. Our study showed that NSAIDs significantly reduced the incidence of PEP (RR, 0.61, 95%CI,0.52–0.72; p < 0.00001). The analysis showed that indomethacin administration post-ERCP (RR, 0.47; 95% CI, 0.31–0.70; p = 0.0002) appeared to be more effective in preventing PEP than indomethacin administration pre-ERCP (RR, 0.59; 95% CI, 0.45–0.79; P = 0.0003), but there was no significant difference between the high-risk and average-risk population(p = 0.13). In the diclofenac group, it was noted that administration of diclofenac pre-ERCP (RR, 0.32; 95% CI, 0.16–0.63; p = 0.001) was more effective than that in post-ERCP (RR, 0.65; 95% CI, 0.27–1.599; p = 0.35). The relative risk of PEP was 0.63 (95% CI, 0.27–1.50; p = 0.30) in high-risk patients and 0.41 (95% CI, 0.17–0.98; p = 0.02) in average-risk patients. With regard to the route of administration, PEP decreased significantly only in patients receiving the drug rectally (RR, 0.53; 95% CI, 0.44–0.63; p < 0.00001), but not for those who received intramuscularly (RR, 0.74; 95% CI, 0.47–1.17; p = 0.20), intravenously (RR, 0.97; 95% CI, 0.51–1.83; p = 0.93), and orally (RR = 0.88; 95% CI, 0.55–0.1.43; p = 0.62).ConclusionsRectal administration of NSAIDs (both indomethacin and diclofenac) was effective in preventing PEP in unselected patients. A single dose of indomethacin after ERCP might be effective in preventing PEP in both high-risk and average-risk patients. However, diclofenac administered rectally before ERCP might be protective against PEP in high-risk patients compared to a placebo. However, more high quality head-to-head RCTs are required.

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Section: Discussionmentioning

confidence: 99%

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

et al. 2018

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“…Some studies have evaluated the preventive effects of rectal indomethacin or diclofenac in post-ERCP pancreatitis, with a meta-analysis con rming their protective effect 11 . Another meta-analysis showed that rectal indomethacin administration prior to ERCP is effective for the prevention of post-ERCP pancreatitis in high-risk patients 12 . Phospholipase A2 activity is inhibited by rectal NSAIDs in acute pancreatitis, possibly regulating proin ammatory mediators.…”

Section: Discussionmentioning

confidence: 99%

Ketorolac and Predicted Severe Acute Pancreatitis: A Randomized, Controlled Clinical Trial

Shahbazi

Shariatpanahi

Shahbazi

2020

Preprint

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Background: We evaluated effect of ketorolac on reducing the severity of acute pancreatitis.Methods: Fifty six adult patients, with predicted severe acute pancreatitis were randomly divided into two groups. The patients in the study group received intravenous ketorolac, 10 mg, 3 times daily from time of enrollment for a maximum of 5 days as needed along with standard medical treatment. Primary outcome measure was the change in the serum level of hs-CRP. Patients were also followed up in terms of hospitalization duration, need for ICU care, development of organ failure, persistent organ failure, pancreatic necrosis, nutritional assessment and mortality. The study was continued to gather clinical follow up information up to 4 months.Results: Serum level of hs-CRP was significantly lower in the ketorolac group than in the control group on days 3, 4, and 5. Organ failure, pseudocyst formation, acute necrotic collection and intensive care unit transfer occurred non-significantly more in the control group than in the ketorolac group. Median days of hospitalization were significantly lower in the study group than in the control group. Based on the Log rank test, survival within 4 months was marginally lower in the control group (P=0.076). The time to start feeding was significantly shorter in the study group than in the control group with no need to artificial enteral nutrition in the ketorolac group. Frequency of NPO (not per oral) was significantly lower in the ketorolac group.Conclusion: The use of ketorolac may improve feeding and clinical outcomes in severe acute pancreatitis.ClinicalTrials.gov: NCT02885441, Date: August 31, 2016

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“…A recently published meta-analysis of 4741 patients from 17 prospective trials showed that rectally administered diclofenac or indomethacin before, or closely after, ERCP were safe and effective in the prevention of PEP in all patients [ 24 ]. Based on pharmacokinetics, the peak plasma concentration of indomethacin and complete bioavailability can be reached 30 min after the rectal administration of indomethacin and the superior effect of its administration before ERCP was confirmed in high-risk patients [ 20 , 25 ]. Thus, our study preferred the strategy of pre-procedural administration.…”

Section: Discussionmentioning

confidence: 99%

Rectally administered indomethacin to prevent post-ESWL-pancreatitis (RIPEP): study protocol for a randomized controlled trial

Qian

Chen

Tang

et al. 2017

Trials

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BackgroundPancreatic extracorporeal shock wave lithotripsy (P-ESWL) is the first-line therapy for large pancreatic duct stones. Although it is a highly effective and safe procedure for the fragmentation of pancreatic stones, it is still not complication-free. Just like endoscopic retrograde cholangiopancreatography (ERCP), pancreatitis is the most common complication. To date, nonsteroidal anti-inflammatory drugs (NSAIDs) have proven to be the only effective prophylactic medication for post-ERCP pancreatitis and the European, American and Japanese Society for Gastrointestinal Endoscopy guidelines have recommended prophylactic rectally administered indomethacin for all patients undergoing ERCP. Given the little research about effective prevention for post P-ESWL pancreatitis, we aim to determine whether rectally administered indomethacin can reduce post-ESWL-pancreatitis.Methods/designThe RIPEP study is a prospective, randomized, double-blinded, placebo-controlled trial. One thousand three hundred and seventy patients with chronic pancreatitis and pancreatic stones (>5 mm in diameter) treated with P-ESWL at Changhai Hospital will be randomly allocated to rectally administered indomethacin or placebo therapy before the procedure. The primary endpoint is the incidence of post-ESWL pancreatitis. Secondary endpoints include the severity of pancreatitis, occurrence rate of asymptomatic hyperamylasemia and other complications.DiscussionThe RIPEP trial is designed to show that rectally administered indomethacin reduces the development and severity of post-ESWL pancreatitis and benefits patients treated with P-ESWL.Trial registrationClinicalTrials.gov, ID: NCT02797067. Registered on 17 November 2016.Electronic supplementary materialThe online version of this article (doi:10.1186/s13063-017-2250-7) contains supplementary material, which is available to authorized users.

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How to select patients and timing for rectal indomethacin to prevent post-ERCP pancreatitis: a systematic review and meta-analysis

Cited by 32 publications

References 31 publications

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

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

Ketorolac and Predicted Severe Acute Pancreatitis: A Randomized, Controlled Clinical Trial

Rectally administered indomethacin to prevent post-ESWL-pancreatitis (RIPEP): study protocol for a randomized controlled trial

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