A Cost-Effectiveness Analysis for Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis Prophylaxis in the United States
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Updated: Oct 21, 2025
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Published on: September 5, 2025
Nikhil R Thiruvengadam1, Monica Saumoy2, Yecheskel Schneider3
1Division of Gastroenterology and Hepatology, Loma Linda University Health, Loma Linda, California; Gastroenterology Division, Perelman School of Medicine, Philadelphia, Pennsylvania; Center for Endoscopic Innovation, Research and Training, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
Insights
Rectal indomethacin is the most cost-effective strategy for preventing post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) in both average-risk and high-risk patients. This finding offers valuable insights for optimizing PEP prophylaxis and reducing healthcare costs.
Area of Science:
- Gastroenterology
- Health Economics
Background:
- Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is a common complication, leading to significant morbidity and healthcare expenses.
- Current PEP prevention strategies include pancreatic stent placement, rectal indomethacin, sublingual nitrates, and aggressive hydration.
Purpose of the Study:
- To determine the cost-effectiveness of various prophylactic strategies for preventing PEP.
- To compare the economic value of different PEP prevention methods in average-risk and high-risk patients.
Main Methods:
- Development of two decision trees to model PEP prophylactic strategies for high-risk and average-risk patients.
- Inclusion of data on incidence rates, transition probabilities, and costs from published literature and public sources.
- Evaluation of outcomes using incremental cost-effectiveness ratios with a willingness-to-pay threshold of $100,000 per quality-adjusted life year (QALY).
Main Results:
- In high-risk patients, all tested strategies were cost-effective compared to no prophylaxis, with rectal indomethacin being the most cost-effective ($31,589/QALY).
- In average-risk patients, rectal indomethacin ($53,016/QALY) and sublingual nitrates were cost-effective compared to no prophylaxis.
- Rectal indomethacin demonstrated superior cost-effectiveness in both patient groups.
Conclusions:
- Rectal indomethacin is the most cost-effective strategy for PEP prevention in both average-risk and high-risk patients undergoing ERCP.
- While most strategies proved cost-effective against no prophylaxis in high-risk patients, further research is needed to enhance the implementation of PEP prevention measures.
Background & Aims:
Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is the most common adverse event after endoscopic retrograde cholangiopancreatography, and is responsible for substantial morbidity and health care expenditures of at least $200 million. Therapies for PEP prevention include pancreatic stent placement (PSP), rectal indomethacin, sublingual nitrates, and aggressive lactated Ringer's hydration. Our objective was to determine which PEP prophylactic strategies are cost effective.
Methods:
We developed 2 separate decision trees to evaluate PEP prophylactic strategies. The first, in high-risk patients, compared rectal indomethacin, PSP, PSP with indomethacin, sublingual nitrates, aggressive hydration with lactated Ringer's, and no prophylaxis. The second, in average-risk patients, compared rectal indomethacin, sublingual nitrates, aggressive hydration, and no prophylaxis. We used incidence rates, transition probabilities, and costs from publications and public data sources. Outcome measures were reported as incremental cost-effectiveness ratios, with a willingness-to-pay (WTP) threshold of $100,000/quality-adjusted life years (QALYs).
Results:
Compared with no prophylaxis, all strategies were cost effective at a WTP of $100,000 in preventing PEP in high-risk patients. When directly compared with each other, rectal indomethacin was the cost-effective strategy in high-risk patients ($31,589/QALYs). In average-risk patients, indomethacin and sublingual nitrates were cost effective at a WTP of $100,000/QALYs compared with no prophylaxis. When directly compared with each other, rectal indomethacin was the cost-effective strategy ($53,016/QALYs).
Conclusions:
Rectal indomethacin was the cost-effective strategy for preventing PEP in both average-risk and high-risk patients undergoing endoscopic retrograde cholangiopancreatography. All strategies were cost effective when compared with no prophylaxis in high-risk patients, whereas all strategies except for aggressive hydration with lactated Ringer's were cost effective in average-risk patients. Further studies are needed to improve the utilization of PEP prevention strategies.
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