Indomethacin and diclofenac in the prevention of post-ERCP pancreatitis: a systematic review and meta-analysis of prospective controlled trials.
OBJECTIVE
Diclofenac and indomethacin are the most studied drugs for preventing post-ERCP pancreatitis (PEP). However, there are no prospective, randomized multicenter trials with a sufficient number of patients for correct evaluation of their efficacy. Our aim was to evaluate all prospective trials published in full text that studied the efficacy of diclofenac or indomethacin and were controlled with placebo or non-treatment for the prevention of PEP in adult patients undergoing ERCP.


METHODS
Systematic search of databases (PubMed, Scopus, Web of Science, Cochrane) for relevant studies published from inception to 30 June 2016.


RESULTS
Our meta-analysis of 4741 patients from 17 trials showed that diclofenac or indomethacin significantly decreased the risk ratio (RR) of PEP to 0.60 (95% confidence interval [CI], 0.46-0.78; P = .0001), number needed to treat (NNT) was 20, and the reduction of RR of moderate to severe PEP was 0.64 (95% CI, 0.43-0.97; P = .0339). The efficacy of indomethacin compared with diclofenac was similar (P = .98). The efficacy of indomethacin or diclofenac did not differ according to timing (P = .99) or between patients with average-risk and high-risk for PEP (P = .6923). The effect of non-rectal administration of indomethacin or diclofenac was not significant (P = .1507), but the rectal route was very effective (P = .0005) with an NNT of 19. The administration of indomethacin or diclofenac was avoided in patients with renal failure. Substantial adverse events were not detected.


CONCLUSIONS
The use of rectally administered diclofenac or indomethacin before or closely after ERCP is inexpensive and safe and is recommended in every patient (without renal failure) undergoing ERCP. (Registration number: CRD42016042726, http://www.crd.york.ac.uk/prospero/.).
Department of Gastroenterology and Medicine, Markusovszky University Teaching Hospital, Szombathely, Hungary.
Árpád
Á
Patai
Biometeorology Research Group, University of Veterinary Medicine, Budapest, Hungary.
Norbert
N
Solymosi
Department of Computer Science, Corvinus University of Budapest, Budapest, Hungary.
László
L
Mohácsi
2nd Department of Medicine, Semmelweis University, Budapest, Hungary.
Árpád V
ÁV
Patai
D000285:Administration, Rectal; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000627:therapeutic use*; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000009:adverse effects*; D018849:Controlled Clinical Trials as Topic; D004008:Diclofenac / Q000627:therapeutic use*; D006801:Humans; D007213:Indomethacin / Q000627:therapeutic use*; D010195:Pancreatitis / Q000209:etiology / Q000517:prevention & control*; D011183:Postoperative Complications / Q000209:etiology / Q000517:prevention & control*
D000894:Anti-Inflammatory Agents, Non-Steroidal; D004008:Diclofenac; D007213:Indomethacin