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).

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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