title: How and when should NSAIDs be used for preventing post-ERCP pancreatitis? A systematic review and meta-analysis.
abstract: BACKGROUND
  Non-steroidal anti-inflammatory drugs (NSAIDs) have been shown to be efficacious to prevent pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP). However, the target patients, the type of NSAID, the route of administration and the time of drug delivery remain unclear, as well as the potential efficacy in reducing the severity of pancreatitis, length of hospital stay and mortality. The objective of the study was to evaluate these questions by performing a systematic review and meta-analysis.
  
  
  METHODS
  Multiple searches were performed in the main databases. Randomized controlled trials (RCTs) comparing NSAIDs vs. placebo in the prevention of post-ERCP pancreatitis were included. Primary endpoint of the study was the efficacy for pancreatitis prevention. Sub-analyses were performed to determine the risk reduction in high and low risk patients, and to define optimal time, route of administration, and type of NSAID. Secondary endpoints were safety, moderate to severe pancreatitis prevention and reduction of hospital stay and mortality.
  
  
  RESULTS
  Nine RCTs enrolling 2133 patients were included. The risk of pancreatitis was lower in the NSAID group than in the placebo group (RR 0.51; 95%CI 0.39-0.66). The number needed to treat was 14. The risk of moderate to severe pancreatitis was also lower in the NSAID group. (RR 0.46; 95%CI 0.28-0.76). No adverse events related to NSAID use were reported. NSAIDs were effective in both high-risk and unselected patients (RR 0.53; 95%CI 0.30-0.93 and RR 0.57; 95%CI 0.37-0.88). In the subanalyses, only rectal administration of either indomethacin (RR 0.54; 95%CI 0.38-0.75) or diclofenac (RR 0.42; 95%CI 0.21-0.84) was shown to be effective. There were not enough data to perform a meta-analysis in hospital stay reduction. No deaths occurred.
  
  
  CONCLUSIONS
  A single rectal dose of indomethacin or diclofenac before or immediately after ERCP is safe and prevents procedure-related pancreatitis both in high risk and in unselected patients.
authors.affiliation: Digestive Diseases Department, Althaia Xarxa Assistencial Universitària de Manresa, Barcelona, Spain; Universitat Internacional de Catalunya, Barcelona, Spain; Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain.
authors.forename: Ignasi
authors.initials: I
authors.lastname: Puig
authors.affiliation: Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain; Digestive Diseases Department, Corporació Sanitària Parc Taulí, Sabadell, Barcelona, Spain; Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Madrid, Spain.
authors.forename: Xavier
authors.initials: X
authors.lastname: Calvet
authors.affiliation: Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain; Internal Medicine Department, Corporació Sanitària Parc Taulí, Sabadell, Barcelona, Spain.
authors.forename: Mireia
authors.initials: M
authors.lastname: Baylina
authors.affiliation: Digestive Diseases Department, Althaia Xarxa Assistencial Universitària de Manresa, Barcelona, Spain; Universitat Internacional de Catalunya, Barcelona, Spain.
authors.forename: Álvaro
authors.initials: Á
authors.lastname: Isava
authors.affiliation: Digestive Diseases Department, Althaia Xarxa Assistencial Universitària de Manresa, Barcelona, Spain; Universitat Internacional de Catalunya, Barcelona, Spain.
authors.forename: Pau
authors.initials: P
authors.lastname: Sort
authors.affiliation: Digestive Diseases Department, Althaia Xarxa Assistencial Universitària de Manresa, Barcelona, Spain; Universitat Internacional de Catalunya, Barcelona, Spain.
authors.forename: Jordina
authors.initials: J
authors.lastname: Llaó
authors.affiliation: Digestive Diseases Department, Althaia Xarxa Assistencial Universitària de Manresa, Barcelona, Spain; Universitat Internacional de Catalunya, Barcelona, Spain.
authors.forename: Francesc
authors.initials: F
authors.lastname: Porta
authors.affiliation: Digestive Diseases Department, Althaia Xarxa Assistencial Universitària de Manresa, Barcelona, Spain; Universitat Internacional de Catalunya, Barcelona, Spain.
authors.forename: Francesc
authors.initials: F
authors.lastname: Vida
mesh_terms: D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000627:therapeutic use*; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000009:adverse effects; D017052:Hospital Mortality; D006801:Humans; D015994:Incidence; D007902:Length of Stay; D010195:Pancreatitis / Q000175:diagnosis / Q000188:drug therapy* / Q000453:epidemiology / Q000209:etiology*; D016032:Randomized Controlled Trials as Topic; D012306:Risk; D012720:Severity of Illness Index; D013997:Time Factors
chemical_list: D000894:Anti-Inflammatory Agents, Non-Steroidal