Pharmacological prevention of post-ERCP pancreatitis: which therapy is best?

The effectiveness of the pharmacological prevention of post-ERCP pancreatitis can be established only from large controlled randomized studies. Over the last decade, fifteen studies dealt with these characteristics and a cumulative series of about 3,000 non-selected patients were evaluated. Cumulating the data of the placebo groups, the median incidence of post-ERCP pancreatitis was 8.7% (mean 9.3%), the range varied from 1.6 to 17.7% likely due to case mix and/or different criteria defining acute pancreatitis. These variables, other than differences in the modalities of the administration of the drugs, could explain their contrasting effectiveness between the studies. Somatostatin and octreotide were the prophylactic drugs more frequently experimented (8 studies) followed by corticosteroids such as hydrocortisone, prednisone or methylprednisolone (four studies) and gabexate (three studies). While octreotide was confirmed to be ineffective, somatostatin and gabexate seem to be the best for the prevention of post-ERCP pancreatitis, but both can present some limits such as unreported sample size calculation in the statistical analysis for somatostatin studies and lack of widespread commercial availability for gabexate. Pharmacoeconomic studies are lacking in English language literature. On this point of view, it seems reasonable and preferable a selective as opposed to universal pharmacological prophylaxis but, actually, the experimented pre-treatments in high-risk patients are ineffective.