What are the treatment options for diabetic gastroparesis (delayed gastric emptying)?

From the Guidelines

Diabetic gastroparesis treatment should begin with dietary modifications, including small, frequent meals low in fat and fiber, along with good glycemic control, as this approach has been shown to be useful in managing symptoms 1. The treatment of diabetic gastroparesis is challenging and requires a multifaceted approach.

Key Considerations

• Dietary changes are essential and should be the first line of treatment, focusing on low-fiber, low-fat meals with a higher proportion of liquid calories 1.
• Medications that can worsen gastrointestinal motility, such as opioids, anticholinergics, and certain diabetes medications like GLP-1 RAs, should be withdrawn if possible, considering the balance of risks and benefits 1.
• For pharmacologic interventions, metoclopramide is the only FDA-approved medication for gastroparesis, but its use is recommended for severe cases and for no longer than 12 weeks due to the risk of serious adverse effects 1.
• Other treatment options include domperidone, available outside the U.S., and erythromycin for short-term use, as well as gastric electrical stimulation, though the evidence for the latter in diabetic gastroparesis is limited 1.

Medication Management

• Metoclopramide can be used at a dose of 5-20 mg tid-qid, but long-term use requires careful monitoring due to the risk of tardive dyskinesia 1.
• Domperidone, when available, can be used at doses of 10-20 mg tid-qid 1.
• Erythromycin, for short-term use, can stimulate gastric motility at doses of 50-100 mg orally 3 times daily before meals 1.
• Antiemetics like ondansetron (4-8 mg orally every 8 hours as needed) can help manage nausea 1.
• For visceral pain, tricyclic antidepressants such as amitriptyline (25-100 mg/day) can be considered 1.

Additional Interventions

• Gastric electrical stimulation and other interventions like endoscopic injection of botulinum toxin A, gastric per-oral endoscopic myotomy (G-POEM), and enteral feeding may be considered in severe, refractory cases 1.
• Cognitive and behavioral therapy, hypnotherapy, can also play a role in managing symptoms and improving quality of life 1. Throughout the treatment process, maintaining optimal blood glucose levels is crucial to prevent hyperglycemia from exacerbating gastroparesis symptoms 1.

From the FDA Drug Label

For the Relief of Symptoms Associated with Diabetic Gastroparesis (Diabetic Gastric Stasis) If only the earliest manifestations of diabetic gastric stasis are present, oral administration of metoclopramide may be initiated. However, if severe symptoms are present, therapy should begin with metoclopramide injection (IM or IV) Doses of 10 mg may be administered slowly by the intravenous route over a 1 to 2 minute period. Administration of Metoclopramide Injection, USP up to 10 days may be required before symptoms subside, at which time oral administration of metoclopramide may be instituted.

Treatment of Diabetic Gastroparesis: Metoclopramide can be used to treat diabetic gastroparesis.

• The dosage is 10 mg, administered orally or intravenously, depending on the severity of symptoms.
• If severe symptoms are present, therapy should begin with metoclopramide injection (IM or IV).
• Administration of Metoclopramide Injection, USP up to 10 days may be required before symptoms subside, at which time oral administration of metoclopramide may be instituted 2.

From the Research

Treatment Options for Diabetic Gastroparesis

• Dietary management is crucial in alleviating symptoms and facilitating better glycemic control 3
• Small frequent meals, using more liquid calories, reducing high fat or high fiber, consuming bezoar forming foods, and adjusting meal carbohydrates based on medications or insulin can help improve upper GI symptoms and glycemic control 3
• Enteral nutrition can be an option for patients who fail to stabilize their weight loss, or for those who cannot gain weight with oral feedings, while total parenteral nutrition is rarely necessary for the patient with gastroparesis 3

Pharmacological Treatment

• Metoclopramide is the only drug approved by the Food and Drug Administration for diabetic gastroparesis 4
• Metoclopramide acts as a dopamine receptor antagonist, improving gastric emptying and having an anti-emetic effect 4
• However, metoclopramide carries a black box warning for use >12 weeks due to the risk of tardive dyskinesia (TD), a movement disorder that may be irreversible 4
• Other prokinetic agents such as domperidone and erythromycin can also enhance gastric motility, but have unwanted side effects and numerous drug interactions 5

Comparison of Treatment Options

• A study comparing metoclopramide and erythromycin found that both drugs improved gastric emptying and symptoms of gastroparesis, but erythromycin had a more pronounced effect on improving gastrointestinal symptoms 6
• Metoclopramide has been shown to stimulate an increase in the rate of gastric emptying and reduce symptoms of gastric stasis in patients with diabetic gastroparesis 7
• Novel investigational motilin receptor and ghrelin agonists, such as mitemcinal and TZP-101, show promise in the treatment of diabetic gastroparesis 5