From the Guidelines
The recommended dose of diclofenac suppository before ERCP is 100 mg administered rectally immediately before or after the procedure. This non-steroidal anti-inflammatory drug (NSAID) helps prevent post-ERCP pancreatitis by reducing inflammation through inhibition of prostaglandin synthesis, as supported by high-quality evidence from the European Society of Gastrointestinal Endoscopy (ESGE) and European Association for the Study of the Liver (EASL) clinical guideline 1. For patients with contraindications to NSAIDs such as renal impairment, active peptic ulcer disease, or NSAID allergy, alternative prophylaxis should be considered. The suppository form is particularly useful in this setting as oral medications may be restricted before the procedure, and the rectal route provides good bioavailability.
- Key points to consider:
- The ESGE/EASL recommends routine rectal administration of 100 mg of diclofenac or indomethacin immediately before or after ERCP in all patients without contraindication 1.
- The use of diclofenac or indomethacin has been shown to reduce the risk of post-ERCP pancreatitis, with a strong recommendation and high-quality evidence 1.
- Patients should be informed about the administration technique and potential side effects, which may include rectal irritation, gastrointestinal discomfort, or allergic reactions.
- This preventive measure is most effective when combined with adequate hydration before and after the procedure.
- In terms of specific patient populations, the ESGE/EASL guideline applies to all patients undergoing ERCP, including those with primary sclerosing cholangitis (PSC) 1.
From the Research
Diclofenac Suppository Dose Pre-ERCP
- The optimal dose of diclofenac suppository for preventing post-ERCP pancreatitis (PEP) is not established, but studies suggest that a dose of 50-100 mg may be effective 2, 3, 4.
- A study found that a 25 mg rectal dose of diclofenac was effective in preventing PEP in elderly patients, with a significant reduction in the incidence of PEP compared to the non-diclofenac group 5.
- Another study compared the effect of a high-dose rectal diclofenac suppository (100 mg) with epinephrine spray on the duodenal papilla, and found that the addition of epinephrine spray did not reduce the risk of PEP 4.
- A meta-analysis of randomized controlled trials found that rectal nonsteroidal anti-inflammatory drugs (NSAIDs), including diclofenac, were effective in preventing PEP, with a significant reduction in the risk of PEP compared to the placebo group 6.
- The timing of administration of rectal NSAIDs, including diclofenac, does not appear to affect their efficacy in preventing PEP, with both pre-ERCP and post-ERCP administration being effective 3, 6.