Glyceryl trinitrate for prevention of pancreatitis after endoscopic retrograde cholangiopancreatography: meta-analysis of randomized, controlled trials

Abstract

Objective The aim of the study was to conduct a meta-analysis of published, full-length, randomized controlled trials (RCTs) evaluating the effect of prophylactic glyceryl trinitrate (GTN) on the prevention of pancreatitis after endoscopic retrograde cholangiopancreatography (PEP) and the prevention of hyperamylasemia. Data sources Literature searches were conducted using PubMed, EMBASE, The Cochrane Library, and Web of Knowledge databases (up to May 2014) using keywords 'post-ERCP', 'pancreatitis', 'ERCP', 'post endoscopic retrograde cholangiopancreatography pancreatitis', 'GTN', 'glyceryl trinitrate', and 'nitroglycerin', and were limited to RCTs. No language restriction was imposed. Study selection The following selection criteria were applied: (i) study design - RCTs; (ii) study population - patients undergoing endoscopic retrograde cholangiopancreatography (ERCP); (iii) intervention - prophylactic administration of GTN; (iv) comparison intervention - control or no treatment; and (v) outcome measures - the overall incidence of PEP, the incidence of moderate to severe PEP, the incidence of hyperamylasemia, and the incidence of adverse effect with prophylactic use of GTN. Data extraction Data from eligible studies were extracted independently by using standard forms. Details of the studies included name of the first author, year of publication, country, setting, sample size, interventions, dosage, follow-up, routes of drug administration, inclusion and exclusion criteria of each study, definition, incidence of PEP (including overall and moderate to severe pancreatitis, respectively) and hyperamylasemia. Data synthesis All statistical analyses were performed using Comprehensive Meta-analysis Version 2. All outcomes were expressed as odds ratio (OR) with 95% confidence interval (CI). Findings Eleven randomized controlled trials (RCTs) involving 2395 patients were included. Eleven RCTs compared GTN with placebo for PEP prevention. Meta-analysis showed that the overall incidence of PEP was significantly reduced by GTN treatment (OR 0.65, 95% CI 0.483-0.784). Nevertheless, GTN administration did not decrease the incidence of moderate to severe PEP (OR 0.687, 95% CI 0.407-1.16). Subgroup analyses revealed that GTN administered sublingually was more effective than transdermal and topical administration in reducing the incidence of PEP. In addition, the incidence of hyperamylasemia was significantly reduced by GTN treatment (OR 0.483, 95% CI 0.289-0.809).