Factors Affecting the Efficacy of Nonsteroidal Anti-inflammatory Drugs in Preventing Post–Endoscopic Retrograde Cholangiopancreatography Pancreatitis

Abstract

Objectives To identify the factors affecting the efficacy of nonsteroidal anti-inflammatory drugs (NSAIDs) in preventing post–endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). Methods We systematically searched databases for relevant studies published from inception to November 2013. Results A meta-analysis of 11 randomized trials (n = 2497) revealed a significant reduction in PEP in patients who received NSAIDs compared with that in patients who received placebo (relative risk [RR], 0.59; 95% confidence interval [CI], 0.41–0.85; P = 0.005). In subgroup analysis by treatment type, indomethacin had no significant effect (RR, 0.66; 95% CI, 0.38–1.15; P = 0.14), whereas other NSAIDs showed significant benefit (RR, 0.51; 95% CI, 0.29–0.91; P = 0.02). Only rectal administration significantly reduced the incidence of PEP (RR, 0.43; 95% CI, 0.32–0.58; P < 0.00001). The risk for PEP was the lowest among patients who received NSAIDs before ERCP (RR, 0.48; 95% CI, 0.29–0.78; P = 0.003). NSAIDs did not significantly reduce the risk of PEP in men (RR, 0.61; 95% CI, 0.34–1.09), patients with sphincter of Oddi dysfunction (RR, 0.98; 95% CI, 0.38–2.54), or patients with pancreatic duct injection (RR, 0.64; 95% CI, 0.35–1.18). Conclusions Rectal administration of NSAIDs (especially diclofenac), before ERCP, seemed to be the most effective strategy for preventing PEP.

Rectal NSAIDs in the prevention of post‐endoscopic retrograde cholangiopancreatography pancreatitis in unselected patients: Systematic review and meta‐analysis

“…The trials assessing orally, intraduodenally, intravenously, and intramuscularly given NSAIDs were not significantly associated with a decreased risk of PEP. In addition, the analyses by Rustagi and Njei and by Ding et al . involved the study evaluating the efficacy of valdecoxib, which was reported not to be effective in the prevention of PEP.…”

“…However, the analysis included studies involving high‐risk patients only . Actually, most of the previous meta‐analyses tended to include both RCT involving unselected patients and RCT involving only high‐risk patients when making the analysis . The most recent meta‐analysis by Inamdar et al .…”

PWE-161 Preventing Post-ERCP Pancreatitis (PEP): The Role of Prophylactic Pancreatic Duct Stenting In The Rectal NSAID era

“…Interestingly though, rectal NSAIDs were only given in high-risk cases at the discretion of the surgeon/ endoscopist and when given, they were not immediately given after ERCP. The latter is relevant as a recent analysis of randomised controlled trials showed that PEP was reduced especially in the group where rectal NSAIDs were given before ERCP [18]. Surprisingly, a recently published randomized controlled trial did not show reduced PEP risks in patients receiving rectal indomethacin [19].…”

“…An explanation could be that most of these patients (70%) were of average risk for PEP. Another explanation for the results could be the use of indomethacin as a meta-analysis of 11 randomised controlled trials showed no significant effect of Indomethacin on preventing PEP compared to other NSAIDs [18]. An awaited prospective randomised study of rectal NSAIDs versus rectal NSAIDs and PD stenting in patients at high risk of PEP may help to resolve this important clinical question [20].…”

NSAR nach ERCP für (fast) jeden Patienten!

“…In kleineren Studien wird seit zirka zehn Jahren immer wieder der prophylaktische E ekt untersucht -mit unterschiedlichen Ergebnissen, die selbst in Metaanalysen nicht immer kongruent waren [2,3]. Au ällig ist die aus unserer Sicht hohe Rate an Post-ERCPPankreatitiden in den meisten der eingeschlossenen Studien (in den Kontrollgruppen teils weit > 10 %).…”