From the Guidelines
The recommended dose of diclofenac sodium suppository before ERCP is 100 mg administered rectally immediately before or after the procedure. This dose is 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. The guideline recommends routine rectal administration of 100 mg of diclofenac or indomethacin immediately before or after ERCP in all patients without contraindication. This recommendation is also supported by other studies, including a guideline on the management of common bile duct stones (CBDS) published in the journal Gut 1.
The use of diclofenac sodium suppository before ERCP has been shown to reduce the risk of post-ERCP pancreatitis by inhibiting phospholipase A2 activity and reducing inflammatory mediators. For optimal effectiveness, it is essential to ensure the suppository is inserted beyond the anal sphincter and retained for absorption. Contraindications to diclofenac sodium suppository include hypersensitivity to NSAIDs, history of GI bleeding, severe renal or hepatic impairment, and third-trimester pregnancy. Patients should be informed about potential side effects, including rectal irritation, gastrointestinal discomfort, and rarely, allergic reactions.
Key points to consider when administering diclofenac sodium suppository before ERCP include:
- The suppository should be inserted rectally immediately before or after the procedure
- The recommended dose is 100 mg
- Contraindications should be carefully evaluated before administration
- Patients should be informed about potential side effects
- Alternative NSAIDs may be considered if the patient has difficulty retaining suppositories, although diclofenac suppositories have shown specific efficacy in this context due to their rapid absorption and anti-inflammatory properties.
From the Research
Diclofenac Sodium Suppository Dose Pre-ERCP
- The optimal dose of diclofenac sodium suppository for preventing post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis is a topic of interest in several studies 2, 3, 4, 5, 6.
- A study published in 2022 found that pre-procedure administration of rectal diclofenac (100-mg) is associated with a significant reduction in post-ERCP pancreatitis incidence compared to post-procedure use 2.
- Another study from 2012 found that low-dose rectal diclofenac (50 mg or 25 mg for patients weighing <50 kg) can prevent post-ERCP pancreatitis, with an incidence of 3.9% in the diclofenac group compared to 18.9% in the control group 3.
- A 2018 study evaluated the safety and efficacy of a 25-mg rectal dose of diclofenac in preventing post-ERCP pancreatitis and found that it might prevent the condition, with an incidence of 4.1% in the diclofenac group compared to 13.7% in the control group 4.
- A 2019 randomized prospective study found that 100 mg rectal suppository diclofenac administered 30-60 minutes before ERCP can effectively prevent post-ERCP pancreatitis, with a significantly lower incidence of pancreatitis and post-ERCP pain in the rectal diclofenac group compared to other groups 5.
- A 2021 study found that a 25 mg rectal dose of diclofenac is effective and safe for preventing post-ERCP pancreatitis in elderly patients, with an incidence of 4% in the diclofenac group compared to 14% in the non-diclofenac group 6.
Key Findings
- The dose of diclofenac sodium suppository used in these studies ranges from 25 mg to 100 mg.
- The timing of administration is typically 30 minutes to 1 hour before ERCP.
- The studies suggest that rectal diclofenac can reduce the incidence of post-ERCP pancreatitis, with some studies finding a significant reduction in incidence and severity of pancreatitis.
- The optimal dose and timing of administration may vary depending on the patient population and individual risk factors.