Prophylaxis for Post-ERCP Pancreatitis Appears Underutilized

Prophylaxis for Post-ERCP Pancreatitis Appears Underutilized

Bret T. Petersen, MD, FASGE, reviewing Smith Z, et al. Am J Gastroenterology 2020 Apr 17.

Post-ERCP pancreatitis (PEP) remains an important adverse event. Indomethacin suppositories and pancreatic duct (PD) stents have both been demonstrated to reduce PEP in patients at high risk for PEP. The authors of this study sought to measure the use of these treatments and to correlate them with the incidence of PEP in broad clinical practice of ERCP. From a commercial database encompassing 26 U.S. health care systems, they identified 26,820 ERCPs performed in narrowly defined high-risk patients over a 10-year period (2009-2018), surrounding the 2012 publication of data on the benefit of prophylactic indomethacin. PEP, defined as a diagnosis of pancreatitis during an emergency room or hospital admission within 5 days of ERCP, occurred in 8.6% of patients. The PEP rate did not decline during the 2012 to 2018 interval, whereas PD stent placement declined quickly after 2012 (40.7% in 2013; 8.5% in 2014; nadir, 3.0%), and indomethacin usage increased in a linear fashion but did not exceed 50% in high-risk patients by 2018.

Bret T. Petersen, MD, FASGE


The use of prophylactic rectal indomethacin for the prevention of PEP has grown only slowly, and it appears to be underutilized, particularly in high-risk patients for whom its benefit is most evident. At the same time, the use of temporary prophylactic pancreatic stents has plummeted, perhaps leaving many appropriate patients without either form of prophylaxis against postprocedure pancreatitis. The recent escalation in cost for indomethacin suppositories may be a constraint to its use. Identification of high-risk patients should be standardized, and indications for prophylactic measures against PEP should be incorporated into quality assurance programs. Local formulation of indomethacin suppositories should be considered for approval by the U.S. Food and Drug Administration, and the potential benefit from alternative nonsteroidal agents should be clarified.

Note to readers: At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.


Smith ZL, Elmunzer BJ, 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. Am J Gastroenterol 2020 Apr 17. (Epub ahead of print) (

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