From the Guidelines
First-line treatment for gastroparesis includes dietary modifications and prokinetic medications, with metoclopramide being the primary prokinetic agent, as stated in the most recent study 1. The primary goal of treatment is to improve gastric emptying and reduce symptoms like nausea, vomiting, early satiety, and abdominal pain.
- Dietary changes involve eating smaller, more frequent meals, limiting fat and fiber intake, and avoiding foods that delay gastric emptying.
- The primary prokinetic agent is metoclopramide (10 mg orally, 30 minutes before meals and at bedtime), which increases gastric motility by blocking dopamine receptors.
- Treatment duration with metoclopramide should be limited to 12 weeks when possible due to the risk of tardive dyskinesia, as noted in 1 and 1. Alternatively, domperidone (10-20 mg orally, 3-4 times daily) may be used in countries where available, as it has fewer central nervous system side effects. Second-line treatments include erythromycin (50-125 mg orally, 3 times daily before meals), which stimulates motilin receptors to enhance gastric emptying, though tachyphylaxis often develops within weeks, as mentioned in 1 and 1. For patients with refractory symptoms, antiemetics like ondansetron (4-8 mg orally, 3 times daily) or prochlorperazine (5-10 mg orally, 3-4 times daily) may help control nausea and vomiting without addressing the underlying motility disorder. More invasive options for severe cases include gastric electrical stimulation, pyloromyotomy, or gastric bypass, as discussed in 1, 1, and 1. These treatments aim to improve gastric emptying and reduce symptoms that characterize gastroparesis, which results from impaired coordination between the stomach, pylorus, and duodenum. It is essential to weigh the benefits and risks of each treatment option, considering the potential for adverse effects and the variable efficacy of different therapies, as highlighted in 1 and 1.
From the FDA Drug Label
Metoclopramide is indicated for the relief of symptoms associated with acute and recurrent diabetic gastric stasis. 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.
The first-line treatment option for managing gastroparesis is metoclopramide (PO), as it is indicated for the relief of symptoms associated with acute and recurrent diabetic gastric stasis.
- The dosage for metoclopramide is not explicitly stated for gastroparesis in the provided drug labels, but it can be initiated orally if only the earliest manifestations of diabetic gastric stasis are present. There is no information in the provided drug labels about second-line treatment options for managing gastroparesis. 2 2
From the Research
First-Line Treatment Options
- The first-line treatment for managing gastroparesis includes prokinetic and antiemetic therapies, with metoclopramide being the only Food and Drug Administration-approved medication for gastroparesis 3, 4, 5, 6.
- Metoclopramide acts as a dopamine receptor antagonist, improving gastric emptying peripherally and having an anti-emetic effect centrally 5, 6.
- Other medications that may be used as first-line treatment include domperidone and erythromycin, although they are not approved for this indication 3, 5.
Second-Line Treatment Options
- Second-line approaches for managing gastroparesis include venting gastrostomy or feeding jejunostomy, as well as intrapyloric botulinum toxin injection, although the latter was not effective in randomized controlled trials 3.
- Other second-line treatment options may include partial gastrectomy and pyloroplasty, although these should be used rarely and only in carefully selected patients 3.
- Centrally acting antidepressants may also be used as symptom modulators in some cases 3.
- Gastric electrical stimulation (GES) may relieve symptoms, including weekly vomiting frequency, and the need for nutritional supplementation, based on open-label studies 3.