title: Systematic review with network meta-analysis: pharmacological prophylaxis against post-ERCP pancreatitis.
abstract: BACKGROUND
  The efficacy of many pharmacological agents for preventing post-ERCP pancreatitis (PEP) has been evaluated in randomised controlled trials (RCTs), but it is unclear which agent(s) should be used in clinical practice. Network meta-analyses of RCTs are used to simultaneously compare several agents to determine their relative efficacy and identify priority agents for comparison in future RCTs.
  
  
  OBJECTIVE
  To evaluate pharmacological agents for the prevention of PEP by conducting a network meta-analysis of RCTs.
  
  
  METHODS
  We searched MEDLINE, EMBASE and Cochrane Library databases for RCTs that evaluated the efficacy of agents for preventing PEP. RCTs were simultaneously analysed using random-effects network meta-analysis under the Bayesian framework to identify the best agents. The efficacy of agents was ordered according to the probability of being ranked as any of the top three best performing agents.
  
  
  RESULTS
  The network meta-analysis included 99 RCTs evaluating 16 agents in 25 313 patients. Topical epinephrine (adrenaline) was the most efficacious agent with 85.9% probability of ranking among the top three agents, followed by nafamostat (51.4%), antibiotics (44.5%) and NSAIDs (42.8%). However, in a sensitivity analysis including only rectal NSAIDs, NSAIDs moved from fourth rank to second (58.1%). Patients receiving topical epinephrine, compared with placebo, had a 75% reduced risk of PEP (OR 0.25, 95% probability interval 0.06-0.66).
  
  
  CONCLUSIONS
  Topical epinephrine and rectal NSAIDs are the most efficacious agents for preventing post-ERCP pancreatitis, based on existing RCTs. Combinations of these agents, which act on different steps in the pathogenesis of post-ERCP pancreatitis, should be evaluated in future trials.
authors.affiliation: Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA.
authors.forename: V S
authors.initials: VS
authors.lastname: Akshintala
authors.forename: S M
authors.initials: SM
authors.lastname: Hutfless
authors.forename: E
authors.initials: E
authors.lastname: Colantuoni
authors.forename: K J
authors.initials: KJ
authors.lastname: Kim
authors.forename: M A
authors.initials: MA
authors.lastname: Khashab
authors.forename: T
authors.initials: T
authors.lastname: Li
authors.forename: B J
authors.initials: BJ
authors.lastname: Elmunzer
authors.forename: M A
authors.initials: MA
authors.lastname: Puhan
authors.forename: A
authors.initials: A
authors.lastname: Sinha
authors.forename: A
authors.initials: A
authors.lastname: Kamal
authors.forename: A M
authors.initials: AM
authors.lastname: Lennon
authors.forename: P I
authors.initials: PI
authors.lastname: Okolo
authors.forename: M K
authors.initials: MK
authors.lastname: Palakurthy
authors.forename: A N
authors.initials: AN
authors.lastname: Kalloo
authors.forename: V K
authors.initials: VK
authors.lastname: Singh
mesh_terms: D000285:Administration, Rectal; D000287:Administration, Topical; D000328:Adult; D000368:Aged; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000008:administration & dosage / Q000627:therapeutic use*; D001499:Bayes Theorem; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000009:adverse effects*; D004359:Drug Therapy, Combination; D004837:Epinephrine / Q000008:administration & dosage / Q000627:therapeutic use*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010195:Pancreatitis / Q000209:etiology / Q000517:prevention & control*; D016032:Randomized Controlled Trials as Topic
chemical_list: D000894:Anti-Inflammatory Agents, Non-Steroidal; D004837:Epinephrine