Rectal Diclofenac Efficacious for Treating Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis

Illustration of the human pancreas.
Investigators ranked and compared the efficacy of different post-ERCP pancreatitis prophylaxis methods.

A systematic review and meta-analysis found that rectal diclofenac had the most evidence for being an effective method of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis prophylaxis. These findings were published in Lancet Gastroenterology and Hepatology.

Researchers searched publication databases through November 15, 2020 for post-ERCP pancreatitis prophylaxis. A total of 55 randomized controlled trials consisting of 17,062 patients assigned to 20 different interventions, placebos, or active controls were included.

Patient populations included between 35.9% and 86.5% women with a mean age range of 44 to 74 years. Interventions included diclofenac, indomethacin, celecoxib, naproxen, and ketoprofen. Mean post-ERCP pancreatitis rate was 12.2% (95% CI, 11.4%-13.0%) among the placebo/active control groups.

Compared with placebo, 16 modalities outperformed and 4 performed poorer than placebo. The 3 combinatorial modalities which were tested were in the top 7 performers, indicating that combinatorial therapies may be more efficacious than monotherapies for post-ERCP pancreatitis.

The modalities with the strongest efficacy for treating post-ERCP pancreatitis were intravenous saline with 100 mg rectal indomethacin (odds ratio [OR], 0.02; 95% CI, 0.00-0.40), 75 mg intramuscular diclofenac (OR, 0.24; 95% CI, 0.09-0.69), high-volume intravenous Ringer’s lactate with 100 mg rectal diclofenac (OR, 0.30; 95% CI, 0.16-0.55), intravenous high-volume Ringer’s lactate (OR, 0.31; 95% CI, 0.12-0.78), and 5-7-Fr pancreatic stent (OR, 0.35; 95% CI, 0.26-0.48).

The modalities which were less efficacious than placebo were 100 mg intravenous ketoprofen (OR, 1.13; 95% CI, 0.32-3.96), 90 mg intramuscular diclofenac (OR, 1.11; 95% CI, 0.59-2.12), intravenous standard-volume Ringer’s lactate (OR, 1.04; 95% CI, 0.37-2.88), and 50 mg oral diclofenac (OR, 1.03; 95% CI, 0.63-1.68).

The investigators did not observe any evidence of publication bias in their meta-analysis (P =.078). Additionally, there was no evidence of inconsistency (P =.46) or heterogeneity (I2, 11.8%; P =.14).

This study may have been limited, as a number of the randomized clinical trials included fewer than 100 patients and may be underpowered.

The study authors concluded that rectal diclofenac had the most robust evidence to support its use to treat post-ERCP pancreatitis. The studies which tested combinatorial therapies tended to outperform monotherapies, indicating that additional studies should explore combinatorial therapies for post-ERCP pancreatitis, as they may be more efficacious.

Disclosure: Multiple authors declared affiliations with industry. Please refer to the original article for a full list of disclosures.


Akshintala VS, Weiland CJS, Bhullar FA, et al. Non-steroidal anti-inflammatory drugs, intravenous fluids, pancreatic stents, or their combinations for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: a systematic review and network meta-analysis. Lancet Gastroenterol Hepatol. 2021;6(9)733-742. doi:10.1016/S2468-1253(21)00170-9