Rectal nonsteroidal anti-inflammatory drugs and pancreatic stents in preventing post-endoscopic retrograde cholangiopancreatography pancreatitis in high-risk patients: A network meta-analysis

Abstract

Background: 100 mg rectal nonsteroidal anti-inflammatory drugs (NSAIDs) and pancreatic stents both significantly reduce the incidence of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. Direct comparison of randomized controlled trials (RCTs) between them in high-risk patients is absent. We conducted this network meta-analysis to indirectly compare the efficacies of 100 mg rectal NSAIDs and pancreatic stents in preventing post-ERCP pancreatitis (PEP) in high-risk patients and help us decide which is preferred in clinical practice.

Methods: A comprehensive search was done to identify RCTs published in English full-text. Interventions included 100 mg rectal NSAIDs (diclofenac or indomethacin) and pancreatic stents. Only studies with high-risk patients of PEP were included. Meta-analyses of NSAIDs and pancreatic stents were conducted respectively. A network meta-analysis using the Bayesian method was performed.

Results: We included 14 RCTs, 8 on pancreatic stents and 6 on 100 mg rectal NSAIDs in high-risk patients. There was no direct comparison between them. After excluding an outlier study on NSAIDs (n = 144), meta-analyses showed they both significantly and statistically reduced the incidence of PEP in high-risk patients (pancreatic stents: n = 8 studies, random-effects risk ratio (RR)0.41, 95%CI 0.30-0.56, I = 0%; NSAIDs: n = 5 studies, random-effects RR 0.37, 95%CI 0.25-0.54, I = 0%). And network meta-analysis showed efficacy of 100 mg rectal NSAIDs was equal to pancreatic stents (random-effects RR 0.94, 95%CI 0.50-1.8).

Conclusions: The efficacy of 100 mg rectal NSAIDs (diclofenac or indomethacin) seems equally significant to pancreatic stents in preventing PEP in high-risk patients. Considering the cost-effectiveness and safety, 100 mg diclofenac or indomethacin may be preferred.

Figure 1

Flowchart of the selection process.

Figure 2

Consensus risk of bias assessment of the included studies on pancreatic stent. Green, low risk; yellow, unclear; red, high risk.

Figure 3

Consensus risk of bias assessment of the included studies on rectal nonsteroidal anti-inflammatory drugs (diclofenac or indomethacin). Green, low risk; yellow, unclear; red, high risk.

Figure 4

Forest plot of comparison of incidence of post-endoscopic retrograde cholangiopancreatography pancreatitis between pancreatic stent and no stent in high-risk patients. PS = pancreatic stent.

Figure 5

Pancreatic stent significantly reduced the incidence of post-endoscopic retrograde cholangiopancreatography pancreatitis in high-risk patients with a moderate GRADE of evidence. ERCP = endoscopic retrograde cholangiopancreatography, GRADE = Grading of Recommendations Assessment, Development and Evaluation.

Figure 6

Forest plot of comparison of incidence of post-endoscopic retrograde cholangiopancreatography pancreatitis between 100 mg rectal nonsteroidal anti-inflammatory drugs (diclofenac or indomethacin) and placebo in high-risk patients. NSAIDs = nonsteroidal anti-inflammatory drugs.

Figure 7

Forest plot of comparison of incidence of post-endoscopic retrograde cholangiopancreatography pancreatitis between 100 mg rectal nonsteroidal anti-inflammatory drugs (diclofenac or indomethacin) and placebo in high-risk patients after excluding the outlier study. NSAIDs = nonsteroidal anti-inflammatory drugs.

Figure 8

Nonsteroidal anti-inflammatory drugs (diclofenac or indomethacin) significantly reduced the incidence of post-endoscopic retrograde cholangiopancreatography pancreatitis in high-risk patients with a moderate GRADE of evidence. ERCP = endoscopic retrograde cholangiopancreatography, GRADE = Grading of Recommendations Assessment, Development and Evaluation, NSAIDs = nonsteroidal anti-inflammatory drugs (diclofenac or indomethacin).

Figure 9

Network graph of the included studies. The thicknesses of the lines represented the number of comparisons. NSAIDs, nonsteroidal anti-inflammatory drugs (diclofenac or indomethacin); PS, pancreatic stent.