Effect of acetylsalicylic acid, clopidogrel, and indomethacin on bleeding after sphincterotomy: the good, the better, and no-one is ugly

We read with great interest the article by Hamada et al. on bleeding after sphincterotomy (BAS) [1]. The authors presented a Japanese, retrospective, observational study showing that continuation of antiplatelet agents does not influence BAS. Their conclusions can be confirmed by our “post hoc” analysis [2] using prospective clinical trial data [3] on the effect of indomethacin in the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. In our prospective, randomized, placebo-controlled study [3], we included 576 patients who received 100 mg rectal indomethacin before endoscopic sphincterotomy. Acetylsalicylic acid (ASA) was continued in 87 patients before ERCP, as per UK guidelines [4], and clopidogrel was continued in 29 patients in whom urgent biliary sphincterotomy was required. The frequency of BAS did not increase in patients who were treated by either ASA or clopidogrel during sphincterotomy, and BAS was not altered even in patients receiving rectal indomethacin. Our conclusions were that ASA, clopidogrel, and indomethacin did not influence BAS, and therefore their benefits can be enjoyed without any compromises. However, as only a small number of patients were treated with clopidogrel, we recommend further investigation of this issue by multicenter, prospective, randomized studies.

• References

• 1 Hamada T, Yasunaga H, Nakai Y et al. Bleeding after endoscopic sphincterotomy or papillary balloon dilation among users of antithrombotic agents. Endoscopy 2015; In press. DOI: DOI: 10.1055/s-0034-1392408.
• 2 Patai Á, Solymosi N, Patai ÁV. Does rectal indomethacin given for prevention of post-ERCP pancreatitis increase bleeding after biliary endoscopic sphincterotomy or cardiovascular mortality? Post hoc analysis using prospective clinical trial data. Medicine 2014; 93: e159
• 3 Patai Á, Solymosi N, Patai ÁV. Effect of rectal indomethacin for preventing post-ERCP pancreatitis depends on difficulties of cannulation: results from a randomized study with sequential biliary intubation. J Clin Gastroenterol 2015; 49: 429-437
• 4 Veitch AM, Baglin TP, Gershlick AH et al. Guidelines for the management of anticoagulant and antiplatelet therapy in patients undergoing endoscopic procedures. Gut 2008; 57: 1322-1329