Researchers Compare Prophylaxis Treatments for Post-Endoscopic Retrograde Cholangiopancreatography

While non-steroidal anti-inflammatory drugs (NSAIDs), intravenous fluid, and pancreatic stents as singular treatments or in combination with one another have been evaluated in previous randomized controlled trials for the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP), there has not been a comparison of the efficacy of the treatments.

A team, led by Venkata S Akshintala, MD, Division of Gastroenterology, Johns Hopkins Medical Institutions, conducted an exploratory network meta-analysis of previous randomized controlled trials to systematically compare the direct and indirect evidence, while ranking NSAIDs, intravenous fluids, pancreatic stents, or combinations to determine the most efficacious method of prophylaxis for post-ERCP pancreatitis.

Finding the Data

The researchers searched various databases from inception to Nov. 15,2002 for full-text randomized controlled trials that evaluated the efficacy of these treatments for post-ERCP pancreatitis prevention in adult patients undergoing ERCP. Overall, there were 1503 studies identified, 55 of which evaluated 20 interventions in 17,062 patients included in the final analysis.

The team analyzed incidence of post-ERCP pancreatitis across different studies using network meta-analysis under the frequentist framework. This enabled the researchers to obtain pairwise odds ratios (OR) and 95% confidence intervals (CI).

The team evaluated the confidence rating using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system.

Results

The mean incidence of post-ERCP pancreatitis was 12.2% (95% CI, 11.4-13.0) in the placebo or active control group.

Several treatments stood out as efficacious, including normal saline plus rectal indomethacin (OR, 0.02; 95% CI, 0.00–0.40), intramuscular diclofenac 75 mg (OR, 0.24; 95% CI, 0.09–0.69), intravenous high-volume Ringer's lactate plus rectal diclofenac 100 mg (OR, 0.30, 95% CI, 0.16–0.55), intravenous high-volume Ringer's lactate (OR, 0.31; 95% CI, 0.12–0.78), 5–7 Fr pancreatic stents (OR, 0.35; 95% CI, 0.26–0.48), rectal diclofenac 100 mg (OR, 0.36; 95% CI, 0.25–0.52), 3 Fr pancreatic stents (OR, 0.47; 95% CI, 0.26–0.87), and rectal indomethacin 100 mg (OR, 0.60; 95% CI, 0.50–0.73).

In comparison with rectal indomethacin 100 mg, 5–7 Fr pancreatic stents (OR, 0.59; 95% CI, 0.41–0.84), intravenous high-volume Ringer's lactate plus rectal diclofenac 100 mg (OR, 0.49; 95% CI, 0.26–0.94), intravenous standard-volume normal saline plus rectal indomethacin 100 mg (OR, 0.04, 95% CI, 0.00–0.66), and rectal diclofenac 100 mg (OR, 0.59; 95% CI, 0.40–0.89) were more efficacious.

However, the GRADE confidence rating was low to moderate for 98.3% of the pairwise comparisons.

“This systematic review and network meta-analysis summarizes the available literature on NSAIDs, pancreatic stents, intravenous fluids, or combinations of these for prophylaxis of post-ERCP pancreatitis,” the authors wrote. “Rectal diclofenac 100 mg is the best performing rectal NSAID in this network meta-analysis. Combinations of prophylaxis might be more effective, but there is little evidence. These findings help to establish prophylaxis of post-ERCP pancreatitis for future research and practice and could reduce costs and increase adoption of prophylaxis.”

The study, “Non-steroidal anti-inflammatory drugs, intravenous fluids, pancreatic stents, or their combinations for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: a systematic review and network meta-analysis,” was published online in The Lancet Gastroenterology & Hepatology.