No Benefit of Oral Diclofenac on Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis

Ishiwatari, Hirotoshi; Urata, Takahiro; Yasuda, Ichiro; Matsusaki, Shimpei; Hisai, Hiroyuki; Kawakami, Hiroshi; Ono, Michihiro; Iwashita, Takuji; Doi, Shinpei; Kawakubo, Kazumichi; Hayashi, Tsuyoshi; Sonoda, Tomoko; Sakamoto, Naoya; Kato, Junji

doi:10.1007/s10620-016-4251-x

Cited by 23 publications

(17 citation statements)

References 36 publications

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“…With regard to route of administration, NSAIDs were administered via the rectum, IV, IM, and per OS in 12, three, one, and twp studies, respectively. The following NSAIDs were used: diclofenac 17 18 19 20 21 22 23 24 25 26 27 28 , indomethacin 11 29 30 31 32 33 34 , naproxen 35 , valdecoxib 8 , and ketoprofen 36 . Study characteristics are outlined in Table 1 .…”

Section: Resultsmentioning

confidence: 99%

“…Future studies must include both intervention and control groups. In addition, diagnosis of PEP and its changes post-ERCP showed a substantial heterogeneity among the studies, which included time of evaluation after the procedure (from 90 minutes to 72 hours), clinical symptoms (pain, nausea, and vomiting), and use of imaging data (tomography) 11 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 41 .…”

Section: Discussionmentioning

confidence: 99%

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Nonsteroidal anti-inflammatory drugs versus placebo for post-endoscopic retrograde cholangiopancreatography pancreatitis: a systematic review and meta-analysis

et al. 2019

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Background and study aims Endoscopic retrograde cholangiopancreatography (ERCP) is the primary therapeutic procedure for treatment of diseases that affect the biliary tree and pancreatic duct. While the therapeutic success rate of ERCP is high, the procedure can cause complications, such as acute pancreatitis (PEP), bleeding, and perforation. This meta-analysis aimed to assess the efficacy of nonsteroidal anti-inflammatory drugs (NSAIDs) in preventing PEP following (ERCP). Materials and methods We searched databases, such as MEDLINE, Embase, and Cochrane Central Library. Only randomized controlled trials (RCTs) that compared the efficacy of NSAIDs and placebo for the prevention of PEP were included. Outcomes assessed included incidence of PEP, severity of pancreatitis, route of administration, and type of NSAIDs. Results Twenty-one RCTs were considered eligible with a total of 6854 patients analyzed. Overall, 3427 patients used NSAIDs before ERCP and 3427 did not use the drugs (control group). In the end, 250 cases of acute pancreatitis post-ERCP were diagnosed in the NSAIDs group and 407 cases in the placebo group. Risk for PEP was lower in the NSAID group (risk difference (RD): −0.05; 95 % confidence interval (CI): −0.07 to – 0.03; number need to treat (NNT), 20; P < 0.05). Use of NSAIDs effectively prevented mild pancreatitis compared with use of placebo (2.5 % vs. 4.1 %; 95 % CI, −0.05 to – 0.01; NNT, 33; P < 0.05), but the information on moderate and severe PEP could not be completely elucidated. Only rectal administration reduced incidence of PEP (6.8 % vs. 13 %; 95 % CI, −0.10 to – 0.04; NNT, 20; P < 0.05). Furthermore, only diclofenac or indomethacin use was effective in preventing PEP. Conclusions Rectal administration of diclofenac and indomethacin significantly reduced risk of developing mild PEP. Further RCTs are needed to compare efficacy between NSAID administration pathways in prevention of PEP after ERCP.

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Section: Resultsmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Nonsteroidal anti-inflammatory drugs versus placebo for post-endoscopic retrograde cholangiopancreatography pancreatitis: a systematic review and meta-analysis

et al. 2019

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“…The administration route is also significant as NSAIDs administered via the rectal route effectively prevents PEP [7,9,11,12]. In contrast, the administration of NSAIDs through other routes has not been found useful [1,16,17]. There is still some controversy regarding the appropriate timing of NSAIDs administration (before/during/after ERCP).…”

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

confidence: 99%

“…Many of the RCTs and the systematic analysis we reviewed in this study have shown that NSAIDs are effective in reducing the risk of PEP [ 7 , 9 - 12 ], although a few RCTs have shown that NSAIDs are not useful in PEP prevention [ 1 , 13 , 14 ]. NSAIDs provide improved prophylaxis in patients at high risk of developing PEP, as demonstrated by multiple studies [ 7 , 9 ].…”

Section: Reviewmentioning

confidence: 99%

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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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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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No Benefit of Oral Diclofenac on Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis

Abstract: UMIN000008109.

Cited by 23 publications

References 36 publications

Nonsteroidal anti-inflammatory drugs versus placebo for post-endoscopic retrograde cholangiopancreatography pancreatitis: a systematic review and meta-analysis

Nonsteroidal anti-inflammatory drugs versus placebo for post-endoscopic retrograde cholangiopancreatography pancreatitis: a systematic review and meta-analysis

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

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

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