From the Guidelines
For significant gastric distention due to gastroparesis in a 77-year-old, I strongly recommend starting with dietary modifications and considering metoclopramide or alternative prokinetic medications, while closely monitoring for potential side effects, as evidenced by the most recent guidelines 1.
Treatment Approach
The treatment of significant gastric distention due to gastroparesis in elderly patients requires a careful and multi-faceted approach.
- Dietary modifications are crucial and should include small, frequent, low-fat, low-fiber meals to reduce symptoms.
- Avoiding carbonated beverages and consuming liquids between rather than with meals can also help alleviate symptoms.
- Prokinetic medications such as metoclopramide, which is FDA-approved for the treatment of gastroparesis, can be considered, but its use should be limited to 12 weeks due to the risk of serious adverse effects like extrapyramidal signs 1.
- Alternative prokinetic medications like domperidone (where available) or erythromycin for short-term use can also be considered.
Medication Management
- Metoclopramide can be initiated at a dose of 5-10mg orally 30 minutes before meals and at bedtime, with close monitoring for extrapyramidal side effects, which are more common in elderly patients.
- Domperidone can be considered at a dose of 10mg three times daily, where available.
- Erythromycin can be used at a dose of 50-100mg three times daily before meals for short-term relief.
Additional Considerations
- For immediate symptom relief, a nasogastric tube may be necessary to decompress the stomach.
- Anti-emetics such as ondansetron 4-8mg every 8 hours can help manage associated nausea.
- Blood glucose control is essential if diabetes is the underlying cause of gastroparesis.
- Regular monitoring is crucial in elderly patients due to the increased risk of medication side effects and complications from prolonged gastric distention, including aspiration pneumonia and malnutrition.
- Treatment should be individualized based on comorbidities, medication interactions, and severity of symptoms, as supported by recent guidelines 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. Diabetic Gastroparesis (Diabetic Gastric Stasis) Metoclopramide is indicated for the relief of symptoms associated with acute and recurrent diabetic gastric stasis.
Treatment for Significant Gastric Distention-Gastroparesis:
- Metoclopramide is indicated for the relief of symptoms associated with diabetic gastroparesis.
- For a 77-year-old patient, the dosage should be initiated at approximately one-half the recommended dosage due to potential decreased renal function, and then adjusted as necessary.
- The patient's response to the treatment and potential side effects should be closely monitored 2, 2.
- Geriatric patients should receive the lowest dose of metoclopramide that is effective, and if parkinsonian-like symptoms develop, metoclopramide should generally be discontinued 2.
From the Research
Treatment Options for Gastroparesis
The treatment of gastroparesis aims to control symptoms and maintain adequate nutrition and hydration. Some of the treatment options include:
- Eating small meals and limiting intake of fat and fiber 3
- Increasing caloric intake in the form of liquids 3
- Controlling blood glucose levels in diabetic patients 3
- Medications such as metoclopramide, prochlorperazine, and ondansetron 3, 4, 5
- Alternative prokinetic agents like erythromycin and tegaserod 3, 5
- Symptom modulators like low-dose tricyclic antidepressants 3, 6
Pharmacologic Management
Pharmacologic management of gastroparesis includes prokinetic and antiemetic agents, as well as medications targeting the pylorus 5. The only FDA-approved medication for gastroparesis is metoclopramide 5, 6. Other medications like domperidone and erythromycin are used off-label or as part of clinical trials 4, 5, 6.
Severity of Delayed Gastric Emptying
The severity of delayed gastric emptying can affect treatment responsiveness and patient characteristics 7. Patients with severe delayed gastric emptying are at a higher risk of hospitalizations and emergency department visits 7. Opiate use has been associated with an increased degree of delayed gastric emptying 7.
Treatment Considerations
Treatment considerations for gastroparesis include: