How and when should NSAIDs be used for preventing post-ERCP pancreatitis? A systematic review and meta-analysis

Abstract

Background: Non-steroidal anti-inflammatory drugs (NSAIDs) have been shown to be efficacious to prevent pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP). However, the target patients, the type of NSAID, the route of administration and the time of drug delivery remain unclear, as well as the potential efficacy in reducing the severity of pancreatitis, length of hospital stay and mortality. The objective of the study was to evaluate these questions by performing a systematic review and meta-analysis.

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

“…The recent analysis by Sethi et al, 14 including seven trials, 9,22,23,27,[36][37][38] involved studies assessing rectal indomethacin and diclofenac. Compared with other analyses, which concluded the efficacy of NSAIDs in general, 13,15,30,31 the analysis by Sethi et al 14 concluded that rectal NSAIDs were effective. However, the analysis included studies involving high-risk patients only.…”

“…Our findings resemble several previous meta-analyses on this topic. Among the previous meta-analyses, the analyses by Rustagi and Njei, 30 by Puig et al, 13 by Sajid et al, 31 and by Ding et al, 15 all reported that NSAIDs seemed to have an advantage of reducing the incidence of PEP. However, all of the analyses 13,15,30,31 involved studies that were heterogeneous concerning the route of administration.…”

“…Among the previous meta-analyses, the analyses by Rustagi and Njei, 30 by Puig et al, 13 by Sajid et al, 31 and by Ding et al, 15 all reported that NSAIDs seemed to have an advantage of reducing the incidence of PEP. However, all of the analyses 13,15,30,31 involved studies that were heterogeneous concerning the route of administration. [32][33][34][35] The trials assessing orally, 32 intraduodenally, 33 intravenously, 34 and intramuscularly 35 given NSAIDs were not significantly associated with a decreased risk of PEP.…”

“…9,36,37 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. [13][14][15]30,31 The most recent meta-analysis by Inamdar et al 12 concluded that rectal indomethacin was effective in the prevention of PEP in high-risk patients but not in 'average-risk patients'. However, the result must be interpreted with great caution because of the conflicts between the definition of 'average-risk patients' and the data extraction.…”

“…In addition, the recent meta-analysis by Inamdar et al 12 concluded that rectal indomethacin was not effective in the prevention of PEP in 'average-risk patients'. At the same time, although multiple previous meta-analyses have confirmed the efficacy of NSAIDs in the prevention of PEP, most of them included both RCT involving unselected patients and RCT involving only high-risk patients, such as the meta-analyses by Puig et al, 13 by Sethi et al, 14 and by Ding et al 15 All of these results reflect the controversy of the efficacy of rectal NSAIDs for PEP prophylaxis in unselected patients. In addition, although strong evidence has been given to support prophylactic rectal NSAIDs among high-risk patients for PEP, 9 rare studies involved only low-risk patients.…”