What are the treatment options for gastroparesis?

Treatment Options for Gastroparesis

The primary treatment for gastroparesis includes dietary modifications, antiemetic medications, and prokinetic agents, with more advanced interventions reserved for refractory cases. 1

First-Line Approaches

Dietary Modifications

• Eat frequent smaller meals (5-6 per day)
• Replace solid foods with liquids when symptoms are severe
• Follow a low-fiber, low-fat diet
• Choose foods with small particle size
• Increase liquid calorie proportion 1

Medication Management

Prokinetic Agents

• Metoclopramide:

  • FDA-approved for gastroparesis
  • Dosing: 10 mg orally 30 minutes before meals and at bedtime
  • Limited to 12 weeks of use due to risk of tardive dyskinesia
  • Should be reserved for severe cases unresponsive to other therapies 2, 1
  • Reduce dose by half in patients with creatinine clearance below 40 mL/min 2

• Erythromycin:

  • Alternative prokinetic agent
  • Only effective short-term due to tachyphylaxis
  • Useful for acute exacerbations 1

• Domperidone:

  • Not FDA-approved in the US (available in Canada, Mexico, Europe)
  • Has both prokinetic and antiemetic properties 1, 3

Antiemetic Medications

• Antidopaminergics: Prochlorperazine, trimethobenzamide, promethazine
• Antihistamines: For nausea control
• Anticholinergics: May help with symptoms but can worsen gastric emptying
• Serotonin (5-HT3) receptor antagonists: Ondansetron, granisetron - best used on an as-needed basis 1

Important Medication Considerations

• Withdraw medications that may worsen gastroparesis:
  • Opioids
  • Anticholinergics
  • Tricyclic antidepressants
  • GLP-1 receptor agonists
  • Pramlintide 1
  • Balance risk of removing GLP-1 RAs against their potential benefits 1

Second-Line Approaches for Refractory Cases

Combination Therapy

• Consider combining prokinetic agents when monotherapy fails
• Options include metoclopramide with erythromycin 3

Endoscopic and Surgical Options

• Botulinum toxin injection into the pylorus:

  • May provide modest temporary symptom improvement
  • Limited evidence from open-label trials
  • No placebo-controlled trials reported 1

• Gastric electrical stimulation:

  • FDA-approved for refractory cases
  • Variable efficacy
  • Limited to individuals with severe symptoms unresponsive to other treatments
  • Recent data do not support effectiveness in diabetic gastroparesis 1

• Feeding tubes:

  • Decompressing gastrostomy for severe nausea/vomiting
  • Jejunostomy tubes for nutrition, hydration, and medication administration when oral intake is insufficient 1, 4

Treatment Algorithm

1. Initial management:

   • Dietary modifications + optimize glycemic control (if diabetic)
   • Withdraw medications that delay gastric emptying

2. Mild-moderate symptoms:

   • Add antiemetic agents for nausea/vomiting
   • Consider short course of prokinetics (erythromycin or metoclopramide)

3. Persistent symptoms:

   • Combination therapy with different classes of prokinetics
   • Consider domperidone if available

4. Refractory cases:

   • Consider pyloric botulinum toxin injection
   • Evaluate for gastric electrical stimulation
   • Consider feeding tube placement for nutritional support

Common Pitfalls and Caveats

• Metoclopramide should not be used beyond 12 weeks due to risk of tardive dyskinesia and other extrapyramidal effects 2
• Erythromycin effectiveness diminishes over time due to tachyphylaxis 1
• Symptom improvement may not correlate with improved gastric emptying 4
• Identifying the dominant symptom (fullness, nausea, abdominal pain) helps direct management 4
• Long-term control should not be expected from pyloric botulinum toxin injection 1

Proper management of gastroparesis requires a stepwise approach starting with conservative measures and progressing to more invasive options only when necessary to improve quality of life and reduce morbidity.