Post written by Árpád V. Patai, MD, from Semmelweis University, 2nd Department of Medicine, Budapest, Hungary.
Although post-ERCP pancreatitis (PEP) is the most frequent complication of ERCP and mortality of severe PEP is high, ERCP is still inevitable in our therapeutic armamentarium, so it is fundamental to assess the efficacy of all potential preventive measures, eg, non-steroidal anti-inflammatory drugs (NSAIDs) that can reduce the rate of PEP.
Despite that diclofenac and indomethacin are the most studied drugs for preventing PEP, conclusions of randomized controlled trials, cohort studies, and meta-analyses differ from each other, and so a comprehensive consensus has not emerged with regard to their efficacy. To avoid a high risk for a type 2 statistical error due to reduced sample size, we have collected all prospective trials until June 2016 studying the efficacy of diclofenac and indomethacin for all routes of administration controlled with placebo or non-treatment for the prevention of PEP in adult patients undergoing ERCP.
Based on data for more than 2300 patients in each group, the relative risk (RR) of PEP was decreased by diclofenac and indomethacin to 0.60 and the number needed to treat (NNT) was 20. No significant difference was shown between the two drugs, they were effective in both average-risk and high-risk patients and also prevented moderate to severe PEP. PEP decreased significantly only in rectally treated patients (RR 0.55, NNT 19), but no difference was found whether they were given it before or after ERCP.
Because PEP may be unpredictable and unavoidable, our meta-analysis, including the largest number of patients thus far (466 PEP cases from 4741 patients in 17 trials), confirmed that the use of inexpensive rectally administered diclofenac or indomethacin before or soon after ERCP is effective in preventing PEP and so might be reasonable in every patient without renal failure undergoing ERCP.
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