How to manage gastroparesis caused by adrenal insufficiency?

From the Guidelines

Managing gastroparesis caused by adrenal insufficiency requires treating the underlying adrenal insufficiency with hydrocortisone, typically 15-20 mg in divided doses, as recommended by the ASCO guideline update 1. To address gastroparesis symptoms, dietary modifications are crucial, including eating smaller, more frequent meals, choosing low-fat, low-fiber foods, and avoiding carbonated beverages. Prokinetic medications such as metoclopramide or domperidone can help improve gastric emptying, and anti-emetics like ondansetron may control nausea. Adequate hydration and electrolyte management are vital, especially during gastroparesis flares. The connection between these conditions involves cortisol's role in maintaining normal gastric motility and protecting the gastric mucosa; insufficient cortisol levels can impair stomach emptying and digestive function. Regular monitoring of both conditions is essential, as improvements in adrenal function often lead to improvements in gastroparesis symptoms over time, as suggested by the management guidelines for immune-related adverse events 1. Key considerations include:

• Initiating replacement therapy with hydrocortisone and titrating to a maximum of 30 mg daily total dose for residual symptoms of adrenal insufficiency 1
• Reducing maintenance dosing for symptoms of iatrogenic Cushing’s syndrome and adjusting fludrocortisone based on volume status, sodium level, and renin response 1
• Providing patient education on stress dosing, emergency injections, and medical alert systems to prevent adrenal crisis 1

From the FDA Drug Label

For the Relief of Symptoms Associated With Diabetic Gastroparesis (Diabetic Gastric Stasis) Administer 10 mg of metoclopramide 30 minutes before each meal and at bedtime for two to eight weeks, depending upon response and the likelihood of continued well-being upon drug discontinuation.

The provided drug label does not directly address the management of gastroparesis caused by adrenal insufficiency. The label only discusses the treatment of diabetic gastroparesis. No conclusion can be drawn about the management of gastroparesis caused by adrenal insufficiency from this information 2.

From the Research

Management of Gastroparesis Caused by Adrenal Insufficiency

To manage gastroparesis caused by adrenal insufficiency, the following points should be considered:

• Glucocorticoid replacement therapy is the standard treatment for adrenal insufficiency, and it may also help alleviate symptoms of gastroparesis 3.
• The dosage of glucocorticoids may need to be increased in stressful situations or during febrile disorders to prevent an adrenal crisis 4.
• Conventional glucocorticoid replacement therapy may not fully restore normal health, and alternative treatment strategies, such as modified-release hydrocortisone preparations, may be more effective in managing adrenal insufficiency and its associated symptoms, including gastroparesis 5, 6.
• In some cases, complete recovery from primary adrenal insufficiency and its associated symptoms, including gastroparesis, may be possible with glucocorticoid replacement therapy, especially in younger patients with an acute presentation and no comorbidities 7.

Treatment Strategies

Some key treatment strategies for managing gastroparesis caused by adrenal insufficiency include:

• Glucocorticoid replacement therapy with hydrocortisone, usually at a dosage of 15-25 mg/day 4.
• Increased glucocorticoid dosage during stressful situations or febrile disorders to prevent an adrenal crisis 4.
• Use of modified-release hydrocortisone preparations to more closely mimic the physiological circadian pattern of cortisol secretion 5, 6.
• Monitoring of symptoms and adjustment of treatment as needed to prevent over- or under-treatment 6.