Efficacy and safety of rectal nonsteroidal anti-inflammatory drugs for prophylaxis against post-ERCP pancreatitis: a systematic review and meta-analysis

Rectal nonsteroidal anti-inflammatory drugs (NSAIDs) are not commonly used clinically for preventing post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. To evaluate the efficacy and safety of NSAIDs for post-ERCP prophylaxis, we systematically reviewed sixteen randomized controlled trials (involving 6458 patients) that compared rectal NSAIDs with placebo or no treatment for post-ERCP pancreatitis prophylaxis updated to August 2016. GRADE framework was used to assess the quality of evidence. There was "high quality" evidence that rectal NSAIDs were associated with significant reduction in the risk of overall post-ERCP pancreatitis (RR, 0.55; 95% CI, 0.42-0.71). Subgroup analyses demonstrated that diclofenac (RR, 0.41; 95% CI, 0.19-0.90) was probably superior to indomethacin (RR, 0.58; 95% CI, 0.45-0.75), post-ERCP administration (RR, 0.46; 95% CI, 0.24-0.89) was probably superior to pre-ERCP (RR, 0.53; 95% CI, 0.42-0.67), and that mixed-risk population received more benefits (RR, 0.54; 95% CI, 0.33-0.88) than average-risk population (RR, 0.60; 95% CI, 0.41-0.88), but less than high-risk population (RR, 0.41; 95% CI, 0.19-0.91). Moreover, "high quality" evidence showed that rectal NSAIDs were safe when given as a standard dose (RR = 0.80; 95% CI, 0.47-1.36). In conclusion, this meta-analysis revealed that rectal NSAIDs are effective and safe in the prevention of post-ERCP pancreatitis in populations with all levels of risk.