VIDEO: Rectal indomethacin does not prevent pancreatitis post ERCP

Acute pancreatitis is the most common and feared complication of endoscopic retrograde cholangiopancreatography (ERCP). The incidence of post-ERCP pancreatitis is around 10% with a mortality of 0.7% (Gastrointest Endosc. 2015;81:143-9). Recent advances in noninvasive pancreaticobiliary imaging, risk stratification before ERCP, prophylactic pancreatic stent placement, and administration of nonsteroidal anti-inflammatory drugs (NSAIDs) have improved the overall risk benefit ratio of ERCP.

NSAIDs are potent inhibitors of phospholipase A2, cyclooxygenase, and of the activation of platelets and endothelium, all of which play a central role in the pathogenesis of post-ERCP pancreatitis. NSAIDs constitute an attractive option in clinical practice, because they are inexpensive and widely available with a favorable risk profile. A recent multicenter randomized controlled trial (RCT) of 602 patients at high-risk for post-ERCP pancreatitis showed that rectal indomethacin is associated with a 7.7% absolute and a 46% relative risk reduction of post-ERCP pancreatitis (N Engl J Med. 2012;366:1414-22). These findings have been broadly adapted in endoscopic practice in the United States.

Dr. Georgios Papachristou

The presented RCT by Dr. Levenick and his colleagues evaluated the efficacy of rectal indomethacin in preventing post-ERCP pancreatitis among consecutive patients undergoing ERCP in a single U.S. center. This study was a well designed and conducted RCT following the CONSORT guidelines and utilizing an independent data and safety monitoring board.

The authors reported that rectal indomethacin did not result in reduction of post-ERCP pancreatitis (7.2%) when compared with placebo (4.9%). Of importance, 70% of patients included were at average risk for post-ERCP pancreatitis. Furthermore, despite a calculated sample size of 1,398 patients, the study was terminated early after enrolling only 449 patients based on the interim analysis showing futility to reach a statistically different outcome.

This well executed RCT reports no benefit in administering rectal indomethacin in all patients undergoing ERCP. Evidence strongly supports that rectal indomethacin remains an important advancement in preventing post-ERCP pancreatitis. However, its benefit is likely limited to a selected group of patients, those at high-risk for post-ERCP pancreatitis. Further studies are under way to clarify whether rectal indomethacin alone vs. indomethacin plus prophylactic pancreatic stenting is more effective in preventing post-ERCP pancreatitis in high-risk patients.

Dr. Georgios Papachristou is associate professor of medicine at the University of Pittsburgh. He is a consultant for Shire and has received funding from the National Institutes of Health and the VA Health System.