1
|
Zuo J, Li H, Zhang S, Li P. Nonsteroidal Anti-inflammatory Drugs for the Prevention of Post-endoscopic Retrograde Cholangiopancreatography Pancreatitis. Dig Dis Sci 2024; 69:3134-3146. [PMID: 39102041 PMCID: PMC11415478 DOI: 10.1007/s10620-024-08565-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 07/11/2024] [Indexed: 08/06/2024]
Abstract
Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) remains the most frequent and severe complication following ERCP, elevating both patient suffering and healthcare costs, and posing challenges to the advancement of ERCP techniques. Empirical evidence supports the prophylactic use of nonsteroidal anti-inflammatory drugs (NSAIDs) in the prevention of PEP, especially in high-risk populations, as endorsed by both the American Society for Gastrointestinal Endoscopy (ASGE) and the European Society for Gastrointestinal Endoscopy (ESGE). However, the prophylactic efficacy of NSAIDs in average-risk individuals, alongside the ideal drug selection, dosing, and timing of NSAID administration, remains to be elucidated. Furthermore, the synergistic preventive potential of NSAIDs when integrated with other interventions, such as hydration, pancreatic stenting, somatostatin administration, sublingual nitrate application, and epinephrine, warrants further clarification. In this paper, we conduct an exhaustive review of the prophylactic effect and clinical administration of NSAIDs for PEP. We comprehensively synthesize findings from clinical trials investigating NSAIDs, both in monotherapy and combination regimens, for PEP prevention. Additionally, we scrutinize the current landscape of NSAID usage in clinical practice and evaluate their cost-effectiveness. Future research should concentrate on refining NSAID prophylaxis strategies for PEP in patients at different risk levels, while also enhancing adherence to clinical guidelines and alleviating the issue of NSAID cost inflation.
Collapse
Affiliation(s)
- Jiaxuan Zuo
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, 95, Yongan Road, Xicheng District, Beijing, 100050, China
| | - Hengcun Li
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, 95, Yongan Road, Xicheng District, Beijing, 100050, China
| | - Shutian Zhang
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, 95, Yongan Road, Xicheng District, Beijing, 100050, China
| | - Peng Li
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, 95, Yongan Road, Xicheng District, Beijing, 100050, China.
| |
Collapse
|
2
|
Fogel EL, Lehman GA, Tarnasky P, Cote GA, Schmidt SE, Waljee AK, Higgins PDR, Watkins JL, Sherman S, Kwon RSY, Elta GH, Easler JJ, Pleskow DK, Scheiman JM, El Hajj II, Guda NM, Gromski MA, McHenry L, Arol S, Korsnes S, Suarez AL, Spitzer R, Miller M, Hofbauer M, Elmunzer BJ. Rectal indometacin dose escalation for prevention of pancreatitis after endoscopic retrograde cholangiopancreatography in high-risk patients: a double-blind, randomised controlled trial. Lancet Gastroenterol Hepatol 2020; 5:132-141. [PMID: 31780277 PMCID: PMC10576534 DOI: 10.1016/s2468-1253(19)30337-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 10/03/2019] [Accepted: 10/03/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Although rectal indometacin 100 mg is effective in reducing the frequency and severity of pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP) in high-risk patients, the optimal dose is unknown, and pancreatitis incidence remains high. The aim of this study was to compare the efficacy of two dose regimens of rectal indometacin on the frequency and severity of pancreatitis after ERCP in high-risk patients. METHODS In this randomised, double-blind, comparative effectiveness trial, we enrolled patients from six tertiary medical centres in the USA. Eligible patients were those at high risk for the development of pancreatitis after ERCP. We randomly assigned eligible patients (1:1) immediately after ERCP to receive either two 50 mg indometacin suppositories and a placebo suppository (standard-dose group) or three 50 mg indometacin suppositories (high-dose group). 4 h after the procedure, patients assigned to the high-dose group received an additional 50 mg indometacin suppository, whereas patients in the standard-dose group received an additional placebo suppository. The randomisation schedule, stratified according to study centre and with no other restrictions, was computer generated by an investigator who was uninvolved in the clinical care of any participants, distributed to the sites, and kept by personnel not directly involved with the study. These same personnel were responsible for packaging the drug and placebo in opaque envelopes. Patients, study personnel, and treating physicians were masked to study group assignment. The primary outcome of the study was the development of pancreatitis after ERCP. Analyses were done on an intention-to-treat basis. This trial is registered with ClinicalTrials.gov, number NCT01912716, and enrolment is complete. FINDINGS Between July 9, 2013, and March 22, 2018, 1037 eligible patients were enrolled and randomly assigned to receive either standard-dose (n=515) or high-dose indometacin (n=522). Pancreatitis after ERCP occurred in 141 (14%) of 1037 patients-76 (15%) of 515 patients in the standard-dose indometacin group and 65 (12%) of 522 patients in the high-dose indometacin group (risk ratio [RR] 1·19, 95% CI 0·87-1·61; p=0·32). We observed 19 adverse events that were potentially attributable to study drug. Clinically significant bleeding occurred in 14 (1%) of 1037 patients-six (1%) of 515 patients in the standard-dose indometacin group and eight (2%) of 522 patients in the high-dose indometacin group (p=0·79). Three (1%) of 522 patients in the high-dose indometacin group developed acute kidney injury versus none in the standard-dose group (p=0·25). A non-ST elevation myocardial infarction occurred in the standard-dose indometacin group 2 days after ERCP. A transient ischaemic attack occurred in the high-dose indometacin group 5 days after ERCP. All 19 adverse events, in addition to the 141 patients who developed pancreatitis after ERCP, were considered serious as all required admission to hospital. We observed no allergic reactions or deaths at 30 day follow-up. INTERPRETATION Dose escalation to rectal indometacin 200 mg did not confer any advantage compared with the standard 100 mg regimen, with pancreatitis incidence remaining high in high-risk patients. Current practice should continue unchanged. Further research should consider the pharmacokinetics of non-steroidal anti-inflammatory drugs to determine the optimal timing of their administration to prevent pancreatitis after ERCP. FUNDING American College of Gastroenterology.
Collapse
Affiliation(s)
- Evan L Fogel
- Division of Gastoenterology and Hepatology, Indiana University, Indianapolis, IN, USA.
| | - Glen A Lehman
- Division of Gastoenterology and Hepatology, Indiana University, Indianapolis, IN, USA
| | - Paul Tarnasky
- University of Texas Southwestern, Digestive Health Associates of Texas, Dallas, TX, USA
| | - Gregory A Cote
- Division of Gastroenterology, Medical University of South Carolina, Charleston, SC, USA
| | - Suzette E Schmidt
- Division of Gastoenterology and Hepatology, Indiana University, Indianapolis, IN, USA
| | - Akbar K Waljee
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI, USA
| | - Peter D R Higgins
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI, USA
| | - James L Watkins
- Division of Gastoenterology and Hepatology, Indiana University, Indianapolis, IN, USA
| | - Stuart Sherman
- Division of Gastoenterology and Hepatology, Indiana University, Indianapolis, IN, USA
| | - Richard S Y Kwon
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI, USA
| | - Grace H Elta
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI, USA
| | - Jeffrey J Easler
- Division of Gastoenterology and Hepatology, Indiana University, Indianapolis, IN, USA
| | - Douglas K Pleskow
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - James M Scheiman
- Division of Gastroenterology, University of Virginia, Charlottesville, VA, USA
| | - Ihab I El Hajj
- Division of Gastoenterology and Hepatology, Indiana University, Indianapolis, IN, USA; Division of Gastroenterology, University of Balamand, Beirut, Lebanon
| | - Nalini M Guda
- Division of Gastroenterology, University of Wisconsin, Milwaukee, WI, USA; Aurora St Luke's Medical Center, Milwaukee, WI, USA
| | - Mark A Gromski
- Division of Gastoenterology and Hepatology, Indiana University, Indianapolis, IN, USA
| | - Lee McHenry
- Division of Gastoenterology and Hepatology, Indiana University, Indianapolis, IN, USA
| | - Seena Arol
- University of Texas Southwestern, Digestive Health Associates of Texas, Dallas, TX, USA
| | - Sheryl Korsnes
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI, USA
| | - Alejandro L Suarez
- Division of Gastroenterology, Medical University of South Carolina, Charleston, SC, USA; Division of Gastroenterology, Yale University, New Haven, CT, USA
| | - Rebecca Spitzer
- Division of Gastroenterology, Medical University of South Carolina, Charleston, SC, USA
| | - Marilyn Miller
- Division of Gastroenterology, University of Wisconsin, Milwaukee, WI, USA
| | - Maria Hofbauer
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - B Joseph Elmunzer
- Division of Gastroenterology, Medical University of South Carolina, Charleston, SC, USA
| |
Collapse
|
3
|
Inamdar S, Sejpal DV, Trindade AJ. Response. Gastrointest Endosc 2017; 85:689-690. [PMID: 28215780 DOI: 10.1016/j.gie.2016.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 11/16/2016] [Indexed: 02/08/2023]
Affiliation(s)
- Sumant Inamdar
- Department of Medicine, Division of Gastroenterology, Hofstra Northwell School of Medicine, Long Island Jewish Medical Center, Northwell Health System, New Hyde Park, New York, USA
| | - Divyesh V Sejpal
- Department of Medicine, Division of Gastroenterology, Hofstra Northwell School of Medicine, Long Island Jewish Medical Center, Northwell Health System, New Hyde Park, New York, USA
| | - Arvind J Trindade
- Department of Medicine, Division of Gastroenterology, Hofstra Northwell School of Medicine, Long Island Jewish Medical Center, Northwell Health System, New Hyde Park, New York, USA
| |
Collapse
|