Rectal diclofenac best performing rectal NSAID for Post-ERCP pancreatitis: Lancet

Post-ERCP pancreatitis is seen in patients who have signs and symptoms of acute pancreatitis (i.e. abdominal pain) in addition to increasing pancreatic enzymes. But it is crucial to consider other causes of post-procedural abdominal pain, such as air insufflation and, less commonly, perforation.

Previously, Non-steroidal anti-inflammatory drugs (NSAIDs), intravenous fluid, pancreatic stents, or combinations of these have been assessed in randomized controlled trials (RCTs) for the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. However, the comparative efficacy of these treatments remains under-documented.

A study was conducted by a group of researchers from U.S.A and Netherlands, to carry out an exploratory network meta-analysis of previous Randomised Control Trials to systematically compare the direct and indirect evidence and rank NSAIDs, intravenous fluids, pancreatic stents, or combinations of these to demonstrate the most efficient method of prophylaxis for post-ERCP pancreatitis.

The researchers searched PubMed, Embase, and the Cochrane Central Register from inception to Nov 15, 2020, for full-text RCTs that assessed the efficacy of NSAIDs, pancreatic stents, intravenous fluids, or combinations of these for post-ERCP pancreatitis prevention in adult patients undergoing ERCP.

They selected a total of 1503 studies, of which 55 RCTs evaluating 20 interventions in 17, 062 patients were included in the network meta-analysis.

Summarized data from intention-to-treat analyses were also collected from published reports.

Further, they analyzed the incidence of post-ERCP pancreatitis across studies using network meta-analysis under the frequentist framework, obtaining pairwise odds ratios (ORs) and 95% CIs.

Lastly, they utilized the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system for the confidence rating.

The findings of the study are as follows:

· The mean incidence of post-ERCP pancreatitis in the placebo or active control group was 12·2%

· Normal saline plus rectal indomethacin, intramuscular diclofenac 75 mg, intravenous high-volume Ringer's lactate plus rectal diclofenac 100 mg, intravenous high-volume Ringer's lactate, pancreatic stents, rectal diclofenac 100 mg, 3 Fr pancreatic stents and rectal indometacin 100 mg were all more efficacious than placebo for preventing post-ERCP pancreatitis in pairwise comparisons.

· 5–7 Fr pancreatic stents, intravenous high-volume Ringer's lactate plus rectal diclofenac 100 mg, intravenous standard-volume normal saline plus rectal indometacin 100 mg, and rectal diclofenac 100 mg were more effective than rectal indometacin 100 mg.

· The GRADE confidence rating was low to moderate for 98·3% of the pairwise comparisons.

Thus, the researchers concluded that 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.

Reference:

A study titled, "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 a meta-analysis" by Akshintala V et. al published in The Lancet: Gastroenterology and Hepatology.

https://doi.org/10.1016/S2468-1253(21)00170-9