What are the management options for severe gastroparesis?

From the Guidelines

Management of severe gastroparesis should prioritize a comprehensive approach combining dietary modifications, medications, and sometimes procedural interventions, with a focus on improving gastric emptying, reducing nausea and vomiting, and ensuring adequate nutrition, as recommended by the most recent guidelines 1.

Key Considerations

• Initial treatment should focus on nutritional support with small, frequent, low-fat, low-fiber meals, and liquid nutrition supplements if needed.
• Medication therapy should start with prokinetics such as metoclopramide 10mg 30 minutes before meals and at bedtime (maximum 12 weeks due to risk of tardive dyskinesia), domperidone 10-20mg three times daily (requires special access in some countries), or erythromycin 50-125mg three times daily before meals.
• Antiemetics are crucial for symptom control; options include ondansetron 4-8mg every 8 hours, prochlorperazine 5-10mg three times daily, or promethazine 12.5-25mg every 4-6 hours as needed.

Procedural Interventions

• Endoscopic interventions such as pyloric botulinum toxin injection (100-200 units) or gastric electrical stimulation may benefit selected patients.
• Gastric peroral endoscopic myotomy (G-POEM) is a promising minimally invasive option for severe gastroparesis, particularly for patients with moderate-to-severe symptoms and a solid-phase gastric retention of >20% at 4 hours 1.
• Surgical options including pyloroplasty or gastric bypass are reserved for refractory cases.

Patient Selection

• The decision to offer G-POEM should be based on the full clinical picture, including the Gastroparesis Cardinal Symptom Index (GCSI) score, and not determined solely by gastric emptying scan results or GCSI score 1.
• Patients with primarily nausea and vomiting are more likely to have a good clinical response to G-POEM, while those with abdominal pain are less likely to respond.

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.

For severe gastroparesis management, the recommended approach is to start with metoclopramide injection (IM or IV), administering 10 mg slowly over a 1 to 2 minute period. This treatment may need to be continued for up to 10 days before symptoms subside and oral administration can be initiated 2. Key points to consider include:

• Severe symptoms require immediate initiation of metoclopramide injection
• Dosage of 10 mg administered intravenously
• Duration of treatment may be up to 10 days before switching to oral administration

From the Research

Severe Gastroparesis Management

Severe gastroparesis management involves a multifaceted approach to address the underlying causes, alleviate symptoms, and improve quality of life. The following are key aspects of severe gastroparesis management:

• Assessment and correction of nutritional state, relief of symptoms, improvement of gastric emptying, and glycemic control in diabetics 3
• Oral dietary modifications, enteral nutrition via jejunostomy tube, and parenteral nutrition in severe cases 3
• Medical treatment with prokinetic and antiemetic therapies, including metoclopramide, domperidone, erythromycin, and gastric electrical stimulation (GES) 3, 4
• Second-line approaches, such as venting gastrostomy or feeding jejunostomy, and intrapyloric botulinum toxin injection, although the latter was not effective in randomized controlled trials 3

Treatment Options

Treatment options for severe gastroparesis include:

• Dietary modification to manage symptoms and improve nutritional state 5, 6
• Medications to accelerate gastric emptying, such as prokinetic agents, and antiemetic agents to relieve nausea and vomiting 4, 6
• Gastric electrical stimulation (GES) to relieve symptoms, including weekly vomiting frequency, and the need for nutritional supplementation 3, 4
• Surgery, such as partial gastrectomy and pyloroplasty, although these should be used rarely and only in carefully selected patients 3

Emerging Therapies

Emerging therapies for severe gastroparesis include:

• Novel pharmacologic agents, such as ghrelin, TZP-101, TZP-102, RM-131, tegaserod, prucalopride, naronapride, velusetrag, levosulpiride, and itopride 4
• Interventions directed at the pylorus, such as gastric peroral endoscopic myotomy, although robust sham-controlled trials are needed to evaluate their long-term efficacy 6