title: Evaluation of Pharmacologic Prevention of Pancreatitis After Endoscopic Retrograde Cholangiopancreatography: A Systematic Review.
abstract: OBJECTIVE
  There is controversy over the efficacy of pharmacologic agents for preventing pancreatitis after endoscopic retrograde cholangiopancreatography (PEP). We performed a systematic review of PEP pharmacoprevention to evaluate safety and efficacy.
  
  
  METHODS
  We performed a systematic search of the literature for randomized controlled trials (RCTs) and meta-analyses of PEP pharmacoprevention through February 2014. After identifying relevant studies, 2 reviewers each extracted information on study characteristics, clinical outcomes, and risk of bias. A research classification scale was developed to identify pharmacologic agents ready for clinical use, agents for which a confirmatory RCT should be considered a high priority, agents for which exploratory studies are still necessary, and agents for which additional research should be of low priority. Clinical and research recommendations for each agent were made by consensus after considering research classification results and other important factors such as magnitude of benefit, safety, availability, and cost.
  
  
  RESULTS
  After screening 851 citations and 263 potentially relevant articles, 2 reviewers identified 85 RCTs and 28 meta-analyses that were eligible. On the basis of these studies, rectal nonsteroidal anti-inflammatory drugs were found to be appropriate for clinical use, especially for high-risk cases. Sublingual nitroglycerin, bolus-administered somatostatin, and nafamostat were found to be promising agents for which confirmatory research is warranted. Additional research was found to be required to justify confirmatory RCTs for topical epinephrine, aggressive intravenous fluids, gabexate, ulinastatin, secretin, and antibiotics.
  
  
  CONCLUSIONS
  On the basis of a systematic review, NSAIDs are appropriate for use in prevention of PEP, especially for high-risk cases. Additional research is necessary to clarify the role of other pharmacologic agents. These findings could inform future research and guide clinical decision-making and policy.
authors.affiliation: Division of Digestive and Liver Diseases, University of Texas Southwestern, Dallas, Texas.
authors.forename: Nisa M
authors.initials: NM
authors.lastname: Kubiliun
authors.affiliation: Division of Gastroenterology, University of Michigan Medical Center, Ann Arbor, Michigan.
authors.forename: Megan A
authors.initials: MA
authors.lastname: Adams
authors.affiliation: Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland.
authors.forename: Venkata S
authors.initials: VS
authors.lastname: Akshintala
authors.affiliation: Taubman Health Sciences Library, University of Michigan, Ann Arbor, Michigan.
authors.forename: Marisa L
authors.initials: ML
authors.lastname: Conte
authors.affiliation: Division of Gastroenterology, Indiana University Medical Center, Indianapolis, Indiana; Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina.
authors.forename: Gregory A
authors.initials: GA
authors.lastname: Cote
authors.affiliation: Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina.
authors.forename: Peter B
authors.initials: PB
authors.lastname: Cotton
authors.affiliation: Gedyt Endoscopy Center, Buenos Aires, Argentina.
authors.forename: Jean-Marc
authors.initials: JM
authors.lastname: Dumonceau
authors.affiliation: Division of Gastroenterology, University of Michigan Medical Center, Ann Arbor, Michigan.
authors.forename: Grace H
authors.initials: GH
authors.lastname: Elta
authors.affiliation: Division of Gastroenterology, Indiana University Medical Center, Indianapolis, Indiana.
authors.forename: Evan L
authors.initials: EL
authors.lastname: Fogel
authors.affiliation: Division of Gastroenterology, University of Minnesota, Minneapolis, Minnesota.
authors.forename: Martin L
authors.initials: ML
authors.lastname: Freeman
authors.affiliation: Division of Gastroenterology, Indiana University Medical Center, Indianapolis, Indiana.
authors.forename: Glen A
authors.initials: GA
authors.lastname: Lehman
authors.affiliation: Division of Digestive and Liver Diseases, University of Texas Southwestern, Dallas, Texas.
authors.forename: Mariam
authors.initials: M
authors.lastname: Naveed
authors.affiliation: Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina.
authors.forename: Joseph
authors.initials: J
authors.lastname: Romagnuolo
authors.affiliation: Division of Gastroenterology, University of Michigan Medical Center, Ann Arbor, Michigan.
authors.forename: James M
authors.initials: JM
authors.lastname: Scheiman
authors.affiliation: Division of Gastroenterology, Indiana University Medical Center, Indianapolis, Indiana.
authors.forename: Stuart
authors.initials: S
authors.lastname: Sherman
authors.affiliation: Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland.
authors.forename: Vikesh K
authors.initials: VK
authors.lastname: Singh
authors.affiliation: Division of Gastroenterology, University of Michigan Medical Center, Ann Arbor, Michigan; Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina. Electronic address: elmunzer@musc.edu.
authors.forename: B Joseph
authors.initials: BJ
authors.lastname: Elmunzer
mesh_terms: D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000008:administration & dosage*; D018890:Chemoprevention / Q000379:methods*; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000009:adverse effects*; D006801:Humans; D015201:Meta-Analysis as Topic; D010195:Pancreatitis / Q000517:prevention & control*; D016032:Randomized Controlled Trials as Topic; D016896:Treatment Outcome
chemical_list: D000894:Anti-Inflammatory Agents, Non-Steroidal
keywords: Drug; Outcome; Pancreas; Post-ERCP