What are the treatment options for delayed gastric emptying?

From the Guidelines

Delayed gastric emptying treatment should start with dietary modifications and medications, with metoclopramide (10mg before meals and at bedtime) being the only FDA-approved medication for gastroparesis, as stated in the 2022 AGA clinical practice update on management of medically refractory gastroparesis: expert review 1.

Treatment Options

• Dietary changes: eating smaller, more frequent meals (5-6 per day), limiting high-fat and high-fiber foods, and avoiding carbonated beverages
• Prokinetic agents: metoclopramide (10mg before meals and at bedtime) to increase gastric contractions and relax the pyloric sphincter
• Erythromycin (50-100mg three times daily before meals) to stimulate motilin receptors and enhance gastric emptying
• Domperidone (10mg three to four times daily) as an alternative to metoclopramide with fewer central nervous system side effects, although its availability may vary by country
• Antiemetics: ondansetron (4-8mg every 8 hours) to control nausea and vomiting

Invasive Options

• Gastric electrical stimulation
• Pyloroplasty
• Gastric peroral endoscopic myotomy (G-POEM) for select patients with severe delay in gastric emptying and moderate-to-severe symptoms, as suggested in the 2023 AGA clinical practice update on gastric peroral endoscopic myotomy for gastroparesis: commentary 1

Underlying Conditions

• Treating underlying conditions like diabetes (maintaining good glycemic control) or thyroid disorders is essential
• Avoiding medications that can delay gastric emptying, such as opioids and anticholinergics, whenever possible

Best Practice Advice

• Clinicians should review symptoms and evaluate physical examination findings to exclude disorders that can mimic medically refractory gastroparesis, as recommended in the 2022 AGA clinical practice update on management of medically refractory gastroparesis: expert review 1
• Clinicians should verify appropriate methodology of the gastric emptying study to ensure an accurate diagnosis of delayed gastric emptying
• Clinicians should classify patients with gastroparesis into mild, moderate, or severe based on symptoms and the results of a properly performed gastric emptying study
• Clinicians should identify the predominant symptom and initiate treatment based on that symptom, as suggested in the 2023 AGA clinical practice update on gastric peroral endoscopic myotomy for gastroparesis: commentary 1

From the FDA Drug Label

Metoclopramide is indicated for the relief of symptoms associated with acute and recurrent diabetic gastric stasis. Metoclopramide Injection, USP may be used to stimulate gastric emptying and intestinal transit of barium in cases where delayed emptying interferes with radiological examination of the stomach and/or small intestine.

Treatment Options for Delayed Gastric Emptying:

• Metoclopramide (PO) is indicated for the relief of symptoms associated with acute and recurrent diabetic gastric stasis.
• Metoclopramide Injection, USP may be used to stimulate gastric emptying and intestinal transit of barium in cases where delayed emptying interferes with radiological examination of the stomach and/or small intestine. Key points to consider:
• The dosage and administration of metoclopramide vary depending on the specific indication and patient population 2, 2.
• Metoclopramide can cause serious side effects, including abnormal muscle movements and uncontrolled spasms 2.

From the Research

Treatment Options for Delayed Gastric Emptying

The treatment options for delayed gastric emptying, also known as gastroparesis, can be categorized into several approaches, including dietary modifications, medication, and surgical interventions.

• Dietary Modifications: Patients are advised to eat small meals and limit their intake of fat and fiber 3. Increasing caloric intake in the form of liquids is also recommended.
• Medications:
  • Prokinetic agents such as metoclopramide, domperidone, and erythromycin are commonly used to enhance gastric motility 3, 4.
  • Antiemetic agents like prochlorperazine and ondansetron can be used to control nausea 3.
  • For cases refractory to these treatments, alternative prokinetic agents or symptom modulators like low-dose tricyclic antidepressants may be tried 3.
• Surgical Interventions:
  • Injection of botulinum toxin into the pylorus 3, 4.
  • Placement of a feeding jejunostomy or a gastric electrical stimulator 3, 5.
  • Bedside nasointestinal tube placement using the Cortrak system has also been used in critically ill patients 5.
• Other Therapies:
  • Mechanical therapies such as endoscopic pyloric botulinum toxin injection and gastric electrical stimulation are used in intractable cases 4.
  • Novel investigational motilin receptor and ghrelin agonists like mitemcinal and TZP-101 show promise in the treatment of diabetic gastroparesis 4.
  • Psychological interventions may also be beneficial for some patients 6.

Considerations for Specific Patient Groups

• Diabetic Patients: Control of blood glucose levels is crucial, as poor glycemic control can exacerbate symptoms 3, 4.
• Patients with Opiate Use: Opiate use has been associated with an increased degree of delayed gastric emptying and may require special consideration in treatment plans 7.