Combined use of indomethacin and hydration is the best conservative approach for post-ERCP pancreatitis prevention: A network meta-analysis

Pancreatology. 2021 Oct;21(7):1247-1255. doi: 10.1016/j.pan.2021.07.005. Epub 2021 Jul 24.


Objectives: Post-ERCP pancreatitis (PEP) is a life-threatening complication. Given the lack of a causative treatment for pancreatitis, it is of vital importance to minimize this risk of PEP. Multi-target preventive therapy may be the best choice for PEP prevention as disease development is multifactorial.

Aim: We aimed to assess the efficacy of a combination of indomethacin and hydration - type and amount - for PEP prevention via a network meta-analysis.

Methods: Through a systematic search in three databases, we searched all randomized controlled trials involving hydration and indomethacin and ranked the PEP preventive efficacy with a Bayesian network meta-analysis using the PRISMA for Network Meta-Analyses (PRISMA-NMA) guideline. The RoB2 tool was used for risk of bias assessment, surface under the cumulative ranking curve (SUCRA) for ranking and PROSPERO for the study protocol [reg. no. CRD42018112698]. We used risk ratios (RR) for dichotomous data with 95% credible intervals (95% CrI).

Results: The quantitative analysis included 7559 patients from 24 randomized controlled trials. Based on the SUCRA values, a combination of lactated Ringer's and indomethacin is more effective than single therapy with a 94% certainty. The percent relative risk ratios estimate preventive efficacy 70-99% higher for combinations than single therapies. Aggressive hydration with indomethacin (SUCRA 100%) is also significantly more effective than all other interventions (percent relative effect 94.3-98.1%).

Conclusions: A one-hit-on-each-target therapeutic approach is recommended in PEP prevention with an easily accessible combination of indomethacin and aggressive hydration for all average and high-risk patients without contraindication.

Keywords: Hydration; Indomethacin; Pancreatitis; Post-ERCP; Prevention.

Publication types

  • Meta-Analysis

MeSH terms

  • Anti-Inflammatory Agents, Non-Steroidal* / therapeutic use
  • Bayes Theorem
  • Cholangiopancreatography, Endoscopic Retrograde / adverse effects*
  • Combined Modality Therapy
  • Fluid Therapy* / methods
  • Humans
  • Indomethacin* / therapeutic use
  • Network Meta-Analysis
  • Pancreatitis* / etiology
  • Pancreatitis* / prevention & control
  • Ringer's Lactate / administration & dosage*


  • Anti-Inflammatory Agents, Non-Steroidal
  • Ringer's Lactate
  • Indomethacin