Rectal indomethacin is protective against post-ERCP pancreatitis in high-risk patients but not average-risk patients: a systematic review and meta-analysis

Inamdar, Sumant; Han, Dennis; Passi, Monica; Sejpal, Divyesh V.; Trindade, Arvind J.

doi:10.1016/j.gie.2016.08.034

Cited by 58 publications

(51 citation statements)

References 25 publications

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“…In addition, the quality of evidence for the present outcomes of the review considered critical for clinical decision making was ranked “high” according to the GRADE framework, which could render more precisely and compelling estimates. Recently, one meta-analysis by Inamdar et al 50,. which is currently in press, showed that rectal indomethacin significantly decreases the incidence of post-ERCP in high-risk patients but not in average-risk patients.…”

Section: Discussionmentioning

confidence: 99%

Efficacy and safety of rectal nonsteroidal anti-inflammatory drugs for prophylaxis against post-ERCP pancreatitis: a systematic review and meta-analysis

Hou

Huang

et al. 2017

Sci Rep

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Rectal nonsteroidal anti-inflammatory drugs (NSAIDs) are not commonly used clinically for preventing post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. To evaluate the efficacy and safety of NSAIDs for post-ERCP prophylaxis, we systematically reviewed sixteen randomized controlled trials (involving 6458 patients) that compared rectal NSAIDs with placebo or no treatment for post-ERCP pancreatitis prophylaxis updated to August 2016. GRADE framework was used to assess the quality of evidence. There was “high quality” evidence that rectal NSAIDs were associated with significant reduction in the risk of overall post-ERCP pancreatitis (RR, 0.55; 95% CI, 0.42–0.71). Subgroup analyses demonstrated that diclofenac (RR, 0.41; 95% CI, 0.19–0.90) was probably superior to indomethacin (RR, 0.58; 95% CI, 0.45–0.75), post-ERCP administration (RR, 0.46; 95% CI, 0.24–0.89) was probably superior to pre-ERCP (RR, 0.53; 95% CI, 0.42–0.67), and that mixed-risk population received more benefits (RR, 0.54; 95% CI, 0.33–0.88) than average-risk population (RR, 0.60; 95% CI, 0.41–0.88), but less than high-risk population (RR, 0.41; 95% CI, 0.19–0.91). Moreover, “high quality” evidence showed that rectal NSAIDs were safe when given as a standard dose (RR = 0.80; 95% CI, 0.47–1.36). In conclusion, this meta-analysis revealed that rectal NSAIDs are effective and safe in the prevention of post-ERCP pancreatitis in populations with all levels of risk.

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Section: Discussionmentioning

confidence: 99%

Efficacy and safety of rectal nonsteroidal anti-inflammatory drugs for prophylaxis against post-ERCP pancreatitis: a systematic review and meta-analysis

Hou

Huang

et al. 2017

Sci Rep

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“…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 . concluded that rectal indomethacin was effective in the prevention of PEP in high‐risk patients but not in ‘average‐risk patients’.…”

Section: Discussionmentioning

confidence: 99%

“…countered the guidelines that rectal indomethacin of 100 mg was not effective in the prevention of PEP in unselected patients. In addition, the recent meta‐analysis by Inamdar et al . concluded that rectal indomethacin was not effective in the prevention of PEP in ‘average‐risk patients’.…”

Section: Introductionmentioning

confidence: 99%

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

Shen

Shi

Liang

et al. 2017

Digestive Endoscopy

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“…We read with interest the meta‐analyses by Feng et al . and by Inamdar et al ., objecting to the use of rectal indomethacin for post‐endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) prophylaxis in general patients and in ‘average‐risk patients’, respectively, through analyzing the same six randomized controlled trials (RCT) where patients were unselected.…”

Section: Original Data Of Randomized Controlled Trials Included In Thmentioning

confidence: 99%

“…Inamdar et al . defined ‘average‐risk patients’ as patients not meeting criteria for high‐risk patients for PEP.…”

Section: Original Data Of Randomized Controlled Trials Included In Thmentioning

confidence: 99%

Is rectal indomethacin ineffective in the prevention of post‐endoscopic retrograde cholangiopancreatography pancreatitis in the general population?

Shen

Shi

2017

Digestive Endoscopy

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Is rectal indomethacin ineffective in the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis in the general population? Dear Editor We read with interest the meta-analyses by Feng et al. 1 and by Inamdar et al., 2 objecting to the use of rectal indomethacin for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) prophylaxis in general patients and in 'average-risk patients', respectively, through analyzing the same six randomized controlled trials (RCT) where patients were unselected. Inamdar et al. 2 defined 'average-risk patients' as patients not meeting criteria for high-risk patients for PEP. However, five RCT in the meta-analysis included a proportion of highrisk patients. In another RCT for unselected patients, only patients undergoing successful ERCP within five attempts of cannulation were extracted, but patients with other risk factors could not be separated totally. Inconsistence between inclusion criteria and patients included made the results confusing to the readership. Feng et al. 1 corrected the inconsistency and made the first meta-analysis investigating the effectiveness of rectal indomethacin for PEP prophylaxis in the general population. However, the results may not be convincing for the following reasons. First, Freeman-Tukey transformation, a transformation to stabilize the variance in binomial distributions (one type of univariate distribution), 3 was mistakenly used in this bivariant meta-analysis. Second, relative risks (RR) are preferred in meta-analyses of RCT rather than odds ratio (OR), because OR might be nonÀintuitive in interpretation and can overestimate or underestimate RR in common events. 4 In this meta-analysis, the authors computed OR considering OR to be a close approximation of RR in rare events. However, they should mention this in the Methods and limitations. Third, some data were extracted by mistake and the correct ones are given in Table 1. Herein, we corrected the mistakes above and recalculated the results (Fig. 1), confirming the effectiveness of rectal indomethacin for PEP prophylaxis in general patients and further expanding the indication of this agent for patients receiving ERCP.

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Rectal indomethacin is protective against post-ERCP pancreatitis in high-risk patients but not average-risk patients: a systematic review and meta-analysis

Cited by 58 publications

References 25 publications

Efficacy and safety of rectal nonsteroidal anti-inflammatory drugs for prophylaxis against post-ERCP pancreatitis: a systematic review and meta-analysis

Efficacy and safety of rectal nonsteroidal anti-inflammatory drugs for prophylaxis against post-ERCP pancreatitis: 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

Is rectal indomethacin ineffective in the prevention of post‐endoscopic retrograde cholangiopancreatography pancreatitis in the general population?

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