Efficacy Study of Glyceryl-Trinitrate Patch and Parecoxib (Valdecoxib) for the Prevention of Pancreatitis After Endoscopic Retrograde Cholangiopancreatography (ERCP)
Information source: All India Institute of Medical Sciences, New Delhi
ClinicalTrials.gov processed this data on August 23, 2015 Link to the current ClinicalTrials.gov record.
Condition(s) targeted: ERCP; Pancreatitis
Intervention: Glyceryl - trinitrate (Drug); Valdecoxib (Drug)
Phase: Phase 2/Phase 3
Status: Terminated
Sponsored by: All India Institute of Medical Sciences, New Delhi Official(s) and/or principal investigator(s): Pramod K Garg, M.D., D.M., Study Director, Affiliation: All India Institute of Medical Sciences, New Delhi Vikram Bhatia, M.D., D.M., Principal Investigator, Affiliation: All India Institute of Medical Sciences, New Delhi
Summary
ERCP is a diagnostic and therapeutic procedure that is required in patients with suspected
common bile duct stone, malignant biliary obstruction, biliary fistula, etc. Pancreatitis
may occur as a complication of this procedure after about 5-10% of the ERCP procedures. This
complication manifests as persisting pain 24 hours or more after ERCP, along with raised
levels of pancreatic enzymes in the blood. Most of the cases of post-ERCP pancreatitis are
mild, but may be severe and lead to prolonged hospitalization a few patients. The occurrence
of this complication is unpredictable. There have been a number of attempts to prevent this
complication. These include giving certain drugs before ERCP e. g. octreotide, somatostatin,
steroids, etc. However, these have not been successful. Recently, a study showed that
application of glyceryl trinitrate patch on the skin before ERCP might reduce the incidence
of post ERCP-pancreatitis. Another study showed that per rectal administration of diclofenac
tablet after the ERCP procedure also reduced occurrence of post ERCP pancreatitis. Other
experimental studies have shown that certain anti-inflammatory drugs like cox-2 inhibitors
may also be effective.
The investigators want to study whether transdermal patch of glyceryl trinitrate or
administration of injectable cox-2 inhibitor Valdecoxib (pro-drug Parecoxib) can prevent
post-ERCP pancreatitis in our patients who undergo an ERCP.
Clinical Details
Official title: Effect of Transdermal Glyceryl-Trinitrate and Parecoxib (Valdecoxib) for the Prevention of Post -ERCP Pancreatitis
Study design: Allocation: Randomized, Endpoint Classification: Safety/Efficacy Study, Intervention Model: Parallel Assignment, Masking: Double Blind (Subject, Investigator), Primary Purpose: Prevention
Primary outcome: Frequency of acute pancreatitis after ERCP
Secondary outcome: Frequency of painDegree of hyper-amylasemia
Detailed description:
Acute pancreatitis represents the most common complication after ERCP. The reported
incidence of this complication varies from less than 1% to 40%, but rates of about 10% are
reported in most prospective studies involving non-selected patients. Although most episodes
(about 90%) of post-ERCP pancreatitis are mild, a small percentage of patients (about 10%)
may develop severe pancreatitis resulting in significant morbidity and occasional mortality.
Despite technical improvements in recent years, the incidence of this complication has not
decreased.
The risk factors for development of post ERCP acute pancreatitis are now well known. Balloon
dilatation of sphincter of Oddi, difficult papillary cannulation, pancreatic sphincterotomy
and multiple pancreatic duct injections have been found to be independent risk factors for
post-procedure pancreatitis (Odds ratio of 4. 5, 3. 4, 3. 1, 2. 7 respectively) in a recent
prospective, multicenter study by Freeman et al. Opacification of the main pancreatic duct
alone (MPD) is associated with a 31% incidence of hyperamylasemia. This figure is similar to
the 24% incidence of hyperamylasemia which occurs after cholangiography alone. However both
injection pressure and volume of contrast medium injected into the pancreatic duct
contribute to ductal epithelial or acinar injury by disruption of the intercellular tight
junctions with a backflow into the interstitial space.
The role of the osmolarity and ionic nature of the contrast medium is controversial. However
non-ionic, low osmolarity contrast media is preferred by most endoscopists. Electrocautery
in the vicinity of the MPD orifice may produce edema of the tissues with subsequent
obstruction. Etta et al recently showed that use of pure cutting current significantly
reduced pancreatitis rates when compared with blended current (3% vs 11%).Precut or access
papillotomy is associated with higher risk of pancreatitis when used by endoscopists with
less experience, but not in the hands of experienced endoscopists. Operator experience also
seems to be a potential risk factor for post ERCP complications. Large volume centers
performing > 200 procedures per year had significantly less overall complications (2. 0% vs
7. 1%, p<0. 001) and less complication related deaths (0. 18% vs 0. 75%, p<0. 05), compared to
low volume centers in a large Italian multicenter prospective study.
Various agents have been tried with an aim to prevent post ERCP pancreatitis in the last 10
years. These include Gabexate, Somatostatin, Nifedipine, Octreotide, Hydrocortisone,
Prednisone, Allopurinol, Interleukin-10, and Methylprednisolone which have been evaluated in
randomized controlled studies. Of these agents only Interleukin-10, Somatostatin and Gabexate
have been found efficacious. However 13 patients need to be treated prophylactically with
Somatostatin and 27 with Gabexate to prevent a single case of post ERCP pancreatitis. Hence
these agents are unlikely to be cost-effective or universally applicable. The ideal agent to
prevent this complication should be cheap, widely applicable and have a rational basis.
It has been found that cannulation trauma to the papilla or electrocautery leads to
sphincter of Oddi spasm and/or papillary edema, thus obstructing free flow of pancreatic
juice and contrast with resultant acute pancreatic inflammation.
Akashi et al recently showed that although the frequency of pancreatitis was higher in
patients who underwent sphincterotomy, the frequency of severe pancreatitis within 48 hours
and the worsening of pancreatitis after 48 hours is significantly lower in this group. Thus
the lowering of intraductal pressure after endoscopic sphincterotomy (ES) mitigates the
severity of post procedural pancreatitis.
In fact pancreatic stent placement has been shown to be effective for the prevention of post
ERCP pancreatitis in high risk patients. In a recent randomized trial, patients had either a
5 Fr nasopancreatic catheter/a stent placed at the end of ERCP or no endoprosthesis was
placed. Patients undergoing MPD stenting had a lower frequency of pancreatitis as compared
with those in the control group (28% vs 5%, p<0. 05)10 However pancreatic stenting on a
regular basis is difficult and impractical solution. Repeated attempts to place the
pancreatic stent may cause more harm, and a second procedure may be required to remove the
stent. Hence instituting adequate drainage of MPD at the end of ERCP seems to be rational
and useful but pharmacological rather than mechanical means may be desirable.
Sphincter of Oddi relaxation is modified by cholecystokinin (CCK), vasoactive intestinal
peptide (VIP) and nitric oxide (NO) in the physiological state besides a complex neural
control involving sympathetic, parasympathetic and enteric nervous system. Jurkowska et al
studied the role of nitric oxide (NO) in cerulein induced rat pancreatitis model. It was
found that glyceryl trinitrate (NTG, a NO donor) and L-arginine (a substrate for NO
synthesis) resulted in significant attenuation of pancreatic damage as well as earlier
recovery and augmented cell proliferation in comparison to the saline treated or L-NNA (NO
synthase inhibitor) group.
In a randomized double-blind study, prophylactive treatment with NTG (2mg given sublingually
5 min before endoscopy) was compared with placebo in 186 patients. The incidence of
pancreatitis was lower in the NTG group compared with placebo (7 of 90 vs 17 of 96; p<0. 05).
Mean serum amylase values were similar in the two groups.
A more recent study tested the hypothesis that transdermal NTG could be effective in the
prevention of post ERCP pancreatitis. One hundred forty-four patients were randomized: 71
received a 15mg NTG patch and 73 a placebo patch. In the control group pancreatitis
developed in 11 patients versus 3 in the NTG group (p<0. 05). Twenty four hour to baseline
serum amylase and lipase ratios were also lower in the NTG group. Hence NO donors seem
efficacious in preventing hyperamylasemia and post ERCP pancreatitis Regardless of the
initial trigger, the acinar cell injury leads to oxidative stress, nuclear translocation of
nuclear factor kappa-B and subsequent transcription of chemo and pro-inflammatory cytokines.
This is followed by chemo-attraction and activation of macrophages, T lymphocytes and
neutrophils, which are responsible for acinar necrosis and amplification of the
pro-inflammatory cascade. Finally after amplification by Kupffer cells, systemic
inflammatory response syndrome and multiple organ dysfunction occur. All these events occur
within a very short period of time, likely within an hour or two. There is thus a very short
therapeutic window during which it is theoretically possible to shut the inflammatory
cascade.
Cyclooxygenases (COX) are key enzymes of prostaglandin synthesis and have important role in
the regulation of inflammation. Both isoforms of COX are synthesized in acinar cells and
their expression is differentially regulated. Upon induction of pancreatitis in the rat
model, COX-2 mRNA increases while COX-1 expression remains constant. Song et al studied the
effect of pharmacological inhibition of COX-2 and genetic deletion of COX-2 in cerulein
induced acute pancreatitis in mice. In both groups, the severity of pancreatitis and
pancreatitis induced lung injury was reduced compared with the non-inhibited strains of
COX-2 sufficient mice. This indicates that COX-2 plays an important proinflammatory role in
pancreatitis and that COX-2 inhibitors may be beneficial in preventing acute pancreatitis or
reducing its severity.
Parecoxib is the prodrug of Valdecoxib - a selective COX-2 inhibitor. Following IV or IM
injection, Parecoxib is rapidly converted to Valdecoxib, the pharmacologically active
substance by enzymatic hydrolysis in the liver. Following a single intramuscular injection
of 20mg of Valdecoxib, peak blood levels are achieved in approximately 1 hour. Parecoxib
demonstrates an incidence of gastroduodenal ulceration similar to placebo and in twice daily
doses had no effect on platelet aggregation or bleeding compared to placebo.
Eligibility
Minimum age: 18 Years.
Maximum age: N/A.
Gender(s): Both.
Criteria:
Inclusion Criteria:
- All patients aged 18 years and above undergoing first ERCP procedure
Exclusion Criteria:
- Active acute pancreatitis,
- Lower end malignant bile duct block,
- Patients undergoing repeat procedures,including those with previous
sphincterotomy
- Ongoing therapy with nitrates, calcium channel blockers, somatostatin or octreotide
- Patients with bleeding diathesis.
- Patients with chronic pancreatitis
- Patients with cardiac comorbidity
Locations and Contacts
All India Institute of Medical Sciences, New Delhi, India
Additional Information
Patient information database with comprehensive details of ERCP and its complications, including pancreatitis
Related publications: Kaffes AJ, Bourke MJ, Ding S, Alrubaie A, Kwan V, Williams SJ. A prospective, randomized, placebo-controlled trial of transdermal glyceryl trinitrate in ERCP: effects on technical success and post-ERCP pancreatitis. Gastrointest Endosc. 2006 Sep;64(3):351-7. Epub 2006 May 19. Moretó M, Zaballa M, Casado I, Merino O, Rueda M, RamÃrez K, Urcelay R, Baranda A. Transdermal glyceryl trinitrate for prevention of post-ERCP pancreatitis: A randomized double-blind trial. Gastrointest Endosc. 2003 Jan;57(1):1-7. Cheng CL, Sherman S, Watkins JL, Barnett J, Freeman M, Geenen J, Ryan M, Parker H, Frakes JT, Fogel EL, Silverman WB, Dua KS, Aliperti G, Yakshe P, Uzer M, Jones W, Goff J, Lazzell-Pannell L, Rashdan A, Temkit M, Lehman GA. Risk factors for post-ERCP pancreatitis: a prospective multicenter study. Am J Gastroenterol. 2006 Jan;101(1):139-47. Freeman ML, Guda NM. Prevention of post-ERCP pancreatitis: a comprehensive review. Gastrointest Endosc. 2004 Jun;59(7):845-64. Review.
Starting date: October 2003
Last updated: January 28, 2009
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