Underutilization of Indomethacin for Prevention of Pancreatitis Following ERCP

Chronic Pancreatitis Illustration. (Photo By BSIP/UIG Via Getty Images)
A team of investigators conducted a retrospective study to assess the use of indomethacin as prophylaxis of pancreatitis in patients undergoing endoscopic retrograde cholangiopancreatography.

The use of an indomethacin suppository as pancreatitis prophylaxis during endoscopic retrograde cholangiopancreatography (ERCP) remains underutilized despite the low cost and potential clinical benefit, according to results from a retrospective analysis study published in Pancreas.

Data were collected from Explorys, a commercial database that aggregates electronic health records from 26 healthcare systems in the United States. Patients (N=26,820) who underwent ERCP between 2009 and 2018 and were considered at high risk for post-ERCP pancreatitis (PEP) on the basis of narrow criteria were included. PEP was defined as admittance to an emergency department and a diagnosis of pancreatitis within 5 days of undergoing ERCP.

Patients varied significantly for age (P =.016), race (P <.001), and insurance type or status (P <.001). Performance of ERCP was more common among patients aged >65 years (P =.016), patients who were White (P <.001), and those who had private insurance (P <.001).

In total, 8.6% of patients developed PEP. Rates of PEP significantly decreased between 2016 and 2017 (P <.001); however, this trend did not continue in 2018, and a general increase was observed over time (2009: n=120; odds ratio [OR], 1 vs 2018: n=140; OR, 1.16; P <.001).

Documentation about anesthetic administration was noted for 62.7% of patients. The use of indomethacin increased linearly after 2012 (2009 use, n=30 vs 2018 use, n=570; P <.001). Despite the increase in use, indomethacin was used in less than half of procedures in 2018.

When indomethacin use began to increase, use of a pancreatic duct stent declined (2009 use, n=570 vs 2018 use, n=60; P <.001). Between 2015 and 2018, use of a pancreatic duct stent remained <5% (range, 3.0%–4.7%).

A limitation of this study included reliance on Systematized Nomenclature of Medicine Clinical Terms (SNOMED) codes; the investigators were unable to confirm diagnoses or detect coding errors. These data also did not provide hospital location; therefore, the investigators were unable to correlate results with hospital practice.

The study authors concluded that although indomethacin is widely available, inexpensive, and associated with level I evidence for reducing risk for PEP among high-risk patients, its use remains low and continues to be underutilized. Additional education associated with indomethacin and its benefits is therefore warranted.

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Smith ZL, Elmunzer J, Cooper GS, Chak A. Real-world practice patterns in the era of rectal indomethacin for prophylaxis against post-ERCP pancreatitis in a high-risk cohort. Pancreas. 2020;115(6):934-940. doi:10.14309/ajg.0000000000000623