8 Role of HMG CoA Reductase Inhibitors and Proton Pump Inhibitors in the Prevention of Post ERCP Pancreatitis

Abstract

INTRODUCTION: Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is the most frequent complication following ERCP. Studies have suggested that HMG CoA reductase inhibitors (statins), due to their anti-inflammatory properties, are protective against acute pancreatitis and may lessen the severity. Additionally, it has been postulated that by increasing gastric pH, proton pump inhibitors (PPIs) can prevent premature activation of pancreatic enzymes, reducing the risk of pancreatitis. The role of statins and PPIs in PEP have not been examined. The purpose of this study is to assess the impact of statin and PPI medications on PEP in native papilla ERCP in a tertiary referral center. METHODS: Patients who underwent ERCP in a large tertiary care referral setting were retrospectively reviewed from January 2015–December 2017. 1288 patients were screened, and 226 met inclusion criteria. Patients who had ERCP with a native papilla (index ERCP) were included. Data were extracted from chart review. Over 40 variables including demographics, clinical parameters, and procedure-related data points were collected. Variables were collected toinvestigate factors related to PEP and control for cofounders. PEP was defined using the Cotton criteria. A multivariate regression model was constructed to determine independent predictors of post-ERCP pancreatitis. RESULTS: 226 index ERCPs were collected. Mean age was 58.2 years, 48.7% of the patients were female, and 67.1% were Caucasian. Demographics and clinical variables collected are present in Table 1. The overall rate of PEP was 5.3%. 16.7% of those with PEP were on statin therapy compared to 18.4% (P = 0.88), and 25% of patients who had PEP were on PPIs compared to 41.5% (P = 0.3). The presence of a difficult cannulation was more common in patients with PEP (36.4% vs 12.8%, P = 0.028), as was wire cannulation in the main pancreatic duct (66.7% vs 29.9%, P = 0.008). Variables with a P value < 0.1 were included in a multivariate regression model. The only significant predictors of PEP were difficult cannulation (P = 0.033) and wire cannulation of the MPD (P = 0.021). Subgroup analysis including only patients that had MPD cannulation showed that PPI use (P = 0.025) was an independent predictor of PEP. CONCLUSION: Use of statins was not found to be different between PEP groups. In patients that had MPD cannulation, PPI was a predictor of PEP. Further prospective studies are needed to determine the clinical significance of statin and PPI use in relation to PEP.