{"id":3494,"date":"2016-05-23T10:00:35","date_gmt":"2016-05-23T10:00:35","guid":{"rendered":"https:\/\/endoscopiaterapeutica.net\/pt\/uncategorized\/routine-pre-procedural-rectal-indometacin-versus-selective-post-procedural-rectal-indometacin-to-prevent-pancreatitis-in-patients-undergoing-endoscopic-retrograde-cholangiopancreatography-multicent\/"},"modified":"2021-09-22T12:19:48","modified_gmt":"2021-09-22T12:19:48","slug":"routine-pre-procedural-rectal-indometacin-versus-selective-post-procedural-rectal-indometacin-to-prevent-pancreatitis-in-patients-undergoing-endoscopic-retrograde-cholangiopancreatography-multicent","status":"publish","type":"post","link":"https:\/\/endoscopiaterapeutica.net\/pt\/artigoscomentados\/routine-pre-procedural-rectal-indometacin-versus-selective-post-procedural-rectal-indometacin-to-prevent-pancreatitis-in-patients-undergoing-endoscopic-retrograde-cholangiopancreatography-multicent\/","title":{"rendered":"Artigo comentado : Indometacina retal pr\u00e9 procedimento universal versus p\u00f3s para pacientes selecionados em CPRE. Trial multic\u00eantrico."},"content":{"rendered":"<p style=\"text-align: justify;\">Em estudo multic\u00eantrico, randomizado e controlado publicado na revista Lancet compilando seis centros chineses e envolvendo 2600 pacientes foi avaliado se a administra\u00e7\u00e3o universal (em todos os pacientes) pr\u00e9 CPRE de indometacina \u00e9 mais efetiva que a administra\u00e7\u00e3o p\u00f3s procedimento somente em pacientes de alto risco na preven\u00e7\u00e3o de pancreatite p\u00f3s CPRE.<\/p>\n<h2 style=\"text-align: justify;\">Conhecimento pr\u00e9vio ao estudo:<\/h2>\n<p style=\"text-align: justify;\">A pancreatite p\u00f3s procedimento \u00e9 a complica\u00e7\u00e3o mais comum da CPRE, potencialmente grave, podendo levar a aumento do tempo de interna\u00e7\u00e3o e dos custos hospitalares associados. Trabalhos recentes tem apontado que o uso de stents pancre\u00e1ticos e de anti-inflamat\u00f3rios n\u00e3o ester\u00f3ides podem prevenir a pancreatite p\u00f3s CPRE. Entre as principais drogas e vias de administra\u00e7\u00e3o estudadas, a indometacina via retal parece ser a mais efetiva na preven\u00e7\u00e3o de pancreatite em pacientes de alto e m\u00e9dio risco. Contudo, n\u00e3o est\u00e1 claro qual a popula\u00e7\u00e3o alvo ideal (estratificada por risco ou com uso de forma universal), ou qual o melhor momento da aplica\u00e7\u00e3o (antes ou ap\u00f3s o procedimento).<\/p>\n<p><strong>Objetivo:<\/strong> Avaliar se a administra\u00e7\u00e3o pr\u00e9 procedimento de indometacina retal em todos os pacientes \u00e9 mais efetiva que seu uso p\u00f3s procedimento em pacientes de alto risco, na preven\u00e7\u00e3o de pancreatite p\u00f3s CPRE.<\/p>\n<p><strong>Desenho do estudo:<\/strong> Multic\u00eantrico, randomizado, controlado, envolvendo seis centros na China. Pacientes\u00a0 com papila nativa que iam ser submetidos a CPRE foram selecionados e distribu\u00eddos em dois grupos em propor\u00e7\u00e3o 1:1.<\/p>\n<p style=\"text-align: justify;\">Entre Dezembro de 2013 e Setembro de 2015, 2600 pacientes foram selecionados.<\/p>\n<ul style=\"text-align: justify;\">\n<li>Grupo Indometacina pr\u00e9 exame universal: Dose simples de Indometacina 100 mg, retal, 30 min antes da CPRE, em todos os pacientes (n= 1297)<\/li>\n<li>Grupo Indometacina p\u00f3s exame em risco estratificado: Dose simples de Indometacina 100 mg, imediatamente p\u00f3s a CPRE, em pacientes estratificados como de alto risco (n= 1303)<\/li>\n<\/ul>\n<h2><strong>Resultados<\/strong><\/h2>\n<p style=\"text-align: justify;\">Ocorr\u00eancia de pancreatite p\u00f3s CPRE<\/p>\n<ul style=\"text-align: justify;\">\n<li>Em 47 (4%) dos 1297 pacientes no grupo em que a indometacina foi administrada de forma universal e em 100 (8%) dos 1303 pacientes no grupo indometacina com risco estratificado (risco relativo 0,47; 95% CI 0,34\u20130,66; p&lt;0\u00b70001).<\/li>\n<li>Em 18 (6%) dos 305 pacientes de alto risco no grupo indometacina universal e 35 (12%) dos 281 pacientes de alto risco no grupo de risco estratificado (p=0,0057).<\/li>\n<li>Menos frequente nos pacientes de risco intermedi\u00e1rio no grupo indometacina universal (3% [29\/992]), que no grupo de risco estratificado (6% [65\/1022]), no qual a droga n\u00e3o foi administrada (p=0,0003).<\/li>\n<\/ul>\n<p style=\"text-align: justify;\">Outros eventos al\u00e9m de pancreatite aconteceram em 41\u00a0 pacientes no grupo indometacina universal (3%; dois casos graves) e em 48 pacientes do grupo de risco estratificado (4%; um grave). N\u00e3o houve aumento significativo no risco de sangramento.<\/p>\n<p style=\"text-align: justify;\">Foi evidenciado que o uso de indometacina pr\u00e9 procedimento em casos n\u00e3o selecionados, quando comparado com o grupo que administrou a droga p\u00f3s procedimento em casos estratificados como de alto risco, reduziu a ocorr\u00eancia de pancreatite p\u00f3s CPRE sem aumentar o risco de sangramento. Os autores sugerem portanto, que esses dados favorecem o uso universal de indometacina pr\u00e9 CPRE na aus\u00eancia de contra indica\u00e7\u00f5es a utiliza\u00e7\u00e3o da mesma.<\/p>\n<p class=\"\" style=\"text-align: justify;\">Essa publica\u00e7\u00e3o trouxe grande contribui\u00e7\u00e3o a literatura existente, diante da boa amostra e desenho de estudo utilizados. Entre as interven\u00e7\u00f5es propostas, o uso de indometacina de forma universal pr\u00e9 procedimento se apresenta como uma t\u00e1tica capaz de simplificar a abordagem farmacol\u00f3gica nesses pacientes, em compara\u00e7\u00e3o principalmente ao uso de indometacina ap\u00f3s estratifica\u00e7\u00e3o de risco (grupo que j\u00e1 havia sido muito bem descrito no importante trabalho publicado por Elmunzer e colegas no <em>New England Journal of Medicine<\/em> em 2012). Ajuda tamb\u00e9m, ao ampliar a discuss\u00e3o em rela\u00e7\u00e3o rela\u00e7\u00e3o a real capacidade de preven\u00e7\u00e3o da indometacina na pancreatite p\u00f3s CPRE, diante, por exemplo, dos achados de dois estudos recentes que n\u00e3o demonstraram benef\u00edcio do uso de indometacina peri procedimento quando comparado a placebo (Levenick <em>et al<\/em>, 2016; <span id=\"sbref80\" class=\"reference\"><span class=\"refAuthors\">D\u00f6br\u00f6nte <em>et al<\/em>, 2014<\/span><\/span>). Novos estudos abordando o uso de indometacina s\u00e3o esperados. Possivelmente trabalhos que abordem amostras populacionais maiores, ajudando a fortalecer a evid\u00eancia sobre o papel da droga na preven\u00e7\u00e3o da pancreatite p\u00f3s CPRE, qual o potencial risco de sangramento gastrointestinal e tamb\u00e9m esclarecendo quais os pacientes n\u00e3o se beneficiam do uso.<\/p>\n<h2 style=\"text-align: justify;\">Artigo original :<\/h2>\n<p class=\"\" style=\"text-align: justify;\"><a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/?term=Routine+pre-procedural+rectal+indometacin+versusselective+post-procedural+rectal+indometacin+to+prevent+pancreatitis+in+patients+undergoing+endoscopic+retrograde+cholangiopancreatography%3A+a+multicentre%2Csingle-blinded%2C+randomised+controlled+trial\" target=\"_blank\" rel=\"noopener\">Luo H, Zhao L, Leung J, Zhang R, Liu Z, Wang X, Wang B, Nie Z, Lei T, Li X,Zhou W, Zhang L, Wang Q, Li M, Zhou Y, Liu Q, Sun H, Wang Z, Liang S, Guo X, Tao Q, Wu K, Pan Y, Guo X, Fan D. Routine pre-procedural rectal indometacin versusselective post-procedural rectal indometacin to prevent pancreatitis in patients undergoing endoscopic retrograde cholangiopancreatography: a multicentre,single-blinded, randomised controlled trial. Lancet. 2016 Apr 28. pii:S0140-6736(16)30310-5. doi: 10.1016\/S0140 6736(16)30310-5. [Epub ahead of print] PubMed PMID: 27133971.<\/a><\/p>\n<h2 style=\"text-align: justify;\">Bibliografia :<\/h2>\n<ol>\n<li style=\"text-align: justify;\"><span id=\"sbref60\" class=\"reference\"><span class=\"refAuthors\">Elmunzer, J, Scheiman, JM, Lehman, GA et al. <\/span><span class=\"refTitle\">A randomized trial of rectal indomethacin to prevent post-ERCP pancreatitis. <\/span><span class=\"refSeriesTitle\">N Engl J Med<\/span>. <span class=\"refSeriesDate\">2012<\/span>; <span class=\"refSeriesVolume\">366<\/span>: <span class=\"refPages\">1414\u20131422<\/span><\/span><\/li>\n<li style=\"text-align: justify;\"><span id=\"sbref70\" class=\"reference\"><span class=\"refAuthors\">Levenick, JM, Gordon, SR, Fadden, LL et al. <\/span><span class=\"refTitle\">Rectal indomethacin does not prevent post-ERCP pancreatitis in consecutive patients. <\/span><span class=\"refSeriesTitle\">Gastroenterol<\/span>. <span class=\"refSeriesDate\">2016<\/span>; <span class=\"refSeriesVolume\">150<\/span>: <span class=\"refPages\">911\u2013917<\/span><\/span><\/li>\n<li style=\"text-align: justify;\"><span id=\"sbref80\" class=\"reference\"><span class=\"refAuthors\">D\u00f6br\u00f6nte, Z, Szepes, Z, Izb\u00e9ki, F et al. <\/span><span class=\"refTitle\">Is rectal indomethacin effective in preventing of post-endoscopic retrograde cholangiopancreatography pancreatitis?. <\/span><span class=\"refSeriesTitle\">World J Gastroenterol<\/span>. <span class=\"refSeriesDate\">2014<\/span>; <span class=\"refSeriesVolume\">20<\/span>: <span class=\"refPages\">10151\u201310157<\/span><\/span><\/li>\n<\/ol>\n<p>&nbsp;<\/p>\n<p>Veja tamb\u00e9m :<\/p>\n<p><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/artigoscomentados\/artigo-comentado-cpre-em-pacientes-cirroticos\/\">CPRE em pacientes cirr\u00f3ticos.<\/a><\/p>\n<p><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/artigoscomentados\/artigo-comentado-estrategia-de-cpre-precoce-versus-conduta-conservadora-em-pacientes-com-pancreatite\/\">Estrat\u00e9gia de CPRE precoce versus conduta conservadora em pacientes com pancreatite.<\/a><\/p>\n<p><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/artigoscomentados\/cpre-em-pacientes-com-gastrectomia-a-billroth-ii-previa-30-anos-de-experiencia\/\">CPRE em pacientes com gastrectomia a BIllroth II.<\/a><\/p>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Em estudo multic\u00eantrico, randomizado e controlado publicado na revista Lancet compilando seis centros chineses&hellip;<\/p>\n","protected":false},"author":726,"featured_media":3473,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"categories":[142],"tags":[],"ano":[281],"tipo":[155],"volume":[263],"class_list":["post-3494","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-artigoscomentados","ano-281","tipo-cpre","volume-volume-i"],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v27.2 (Yoast SEO v27.2) - https:\/\/yoast.com\/product\/yoast-seo-premium-wordpress\/ -->\n<title>Artigo comentado : Indometacina retal pr\u00e9 procedimento universal versus p\u00f3s para pacientes selecionados em CPRE. Trial multic\u00eantrico. &#8226; Endoscopia Terapeutica<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/endoscopiaterapeutica.net\/pt\/artigoscomentados\/routine-pre-procedural-rectal-indometacin-versus-selective-post-procedural-rectal-indometacin-to-prevent-pancreatitis-in-patients-undergoing-endoscopic-retrograde-cholangiopancreatography-multicent\/\" \/>\n<meta property=\"og:locale\" content=\"pt_BR\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Artigo comentado : Indometacina retal pr\u00e9 procedimento universal versus p\u00f3s para pacientes selecionados em CPRE. 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