The Skyrocketing Cost of Rectal Indomethacin

Elmunzer, B. Joseph; Hernandez, Inmaculada; Gellad, Walid F.

doi:10.1001/jamainternmed.2020.0099

Cited by 18 publications

(12 citation statements)

References 10 publications

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“…The most recent international guidelines are not consistent on the contribution of each individual patient-or procedure-related risk factor for the development of post-ERCP pancreatitis, such as a non-dilated extrahepatic bile duct system [12,13]. Each risk factor's weight has been determined by a limited number of studies with varying quality of evidence, often predating the implementation of routine NSAID prophylaxis [29,31].…”

Section: Discussionmentioning

confidence: 99%

“…Considering intensive IV hydration, a relatively small percentage of ERCPists reported using this prophylactic measure in our 2020 survey compared to 83% in a 2018 North American survey [ 27 ]. Intensive IV hydration may perhaps be the preferred prophylactic measure in North America given the elevated price of the composite rectal indomethacin in certain countries [ 28 , 29 ]. Despite a network meta-analysis suggesting this combination yields the lowest post-ERCP pancreatitis incidence [ 30 ], the future results of another multicenter randomized controlled trial will provide additional clarification [ 9 ].…”

Section: Discussionmentioning

confidence: 99%

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Increased Use of Prophylactic Measures in Preventing Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis

et al. 2021

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Background Nonsteroidal anti-inflammatory drugs (NSAIDs), pancreatic duct stenting, and intensive intravenous hydration have been proven to prevent post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. Trial participation and guideline changes demanded an assessment of the clinical practice of post-ERCP pancreatitis prophylaxis. Aims The surveys aim to identify points of improvement to inform and educate ERCPists about current evidence-based practice. Methods Two anonymous surveys were conducted among Dutch gastroenterologists in 2013 (n = 408) and 2020 (n = 575) for longitudinal views and attitudes pertaining to post-ERCP pancreatitis prophylaxis and recognition of post-ERCP pancreatitis risk factors. Results In 2013 and 2020, respectively, 121 and 109 ERCPists responded. In the 2013 survey, 98% of them utilized NSAID prophylaxis and 62% pancreatic duct stent prophylaxis in specific cases. In the 2020 survey, the use of NSAIDs (100%), pancreatic duct stents (78%), and intensive intravenous hydration (33%) increased among ERCPists. NSAID prophylaxis was the preferred prophylactic measure for all risk factors in the 2020 survey, except for ampullectomy, pancreatic duct contrast injection, and pancreatic duct cannulation, for which NSAID prophylaxis and pancreatic duct stent combined was equally favored or preferred. Conclusion Rectal NSAIDs are the most applied post-ERCP pancreatitis prophylaxis in the Netherlands, followed by pancreatic duct stents and intensive intravenous hydration. Additionally, there is reason to believe that recent guideline updates and active research participation have led to increased prophylaxis implementation.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Increased Use of Prophylactic Measures in Preventing Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis

et al. 2021

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“…However, in the USA, diclofenac suppositories are not available and indomethacin suppositories are only available from one manufacturer; consequently, the cost has increased from $2 to $340 over the last 15 years; with the addition of hospital charges, the total cost can be several thousand dollars. [ 131 ] Unless the individual has a history of NSAID allergy, rectal NSAIDs are safe and easy to administer. Use of rectal NSAIDs for ERCP prophylaxis (where drug cost is not inflated) is a “no brainer.” The same is true to aggressive pre-ERCP hydration unless there are contraindications, e.g.…”

Section: Pancreatitis Prophylaxis Post-ercp Pancreatitismentioning

confidence: 99%

Controversies in ERCP

Dietrich

Bekkali

Burmeister

et al. 2022

Endoscopic Ultrasound

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The aim of the series of papers on controversies of biliopancreatic drainage procedures is to discuss the pros and cons of the varying clinical practices and techniques in ERCP and EUS for drainage of biliary and pancreatic ducts. The first part focuses on indications, clinical and imaging prerequisites before ERCP, sedation options, post-ERCP pancreatitis (PEP) prophylaxis, and other related technical topics. In the second part, specific procedural ERCP-techniques including precut techniques and its timing as well as management algorithms are discussed. In addition, controversies in EUS-guided bile duct and pancreatic drainage procedures are under preparation.

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“…Reasons accounting for this slow and incomplete adoption include disbelief and confusion because scientific societies recommend NSAIDs in different risk categories of patients ( Table 1 ). Surprisingly, cost could become another reason: a single NSAID suppository costs $ 347 in the United States, and it is billed between $ 50 and $ 5000 to ambulatory patients by Californian hospitals 6 . Therefore, exploration for alternatives that might be even more widely available, easy to use, innocuous, and cheap than NSAIDs is welcome.…”

Section: Tablementioning

confidence: 99%