What are the treatment options for gastroparesis?

Treatment Options for Gastroparesis

The management of gastroparesis should follow a stepwise approach beginning with dietary modifications, followed by pharmacologic therapy with metoclopramide or erythromycin as first-line agents, and advancing to more invasive interventions such as gastric electrical stimulation or enteral feeding for refractory cases. 1

Dietary Modifications (First-Line)

• Implement small, frequent meals (5-6 per day) with low-fat, low-fiber content
• Increase liquid calories and consider foods with small particle size
• Progress to a liquid diet if symptoms are moderate to severe
• Avoid carbonated beverages, alcohol, and smoking 1

These dietary changes are fundamental to managing gastroparesis and should be implemented before or alongside medication therapy.

Pharmacologic Therapy

Prokinetic Agents

1. Metoclopramide (First-line)

   • Dosing: 10 mg orally, 30 minutes before meals and at bedtime
   • Important limitations: Risk of tardive dyskinesia; FDA-limited to 12 weeks of use
   • For severe symptoms, may initiate with injectable form (IM or IV) before transitioning to oral 1, 2
   • Dose reduction needed in renal impairment (CrCl <40 mL/min): start at half the recommended dose 2

2. Erythromycin (Alternative first-line)

   • Dosing: 40-250 mg orally 3 times daily
   • Limitations: Antibiotic resistance concerns and tachyphylaxis (diminishing effect over time) 1

Antiemetic Agents

• Phenothiazines, trimethobenzamide, and serotonin (5-HT3) receptor antagonists can be used as needed for symptom control 1
• These have not been specifically tested in gastroparesis but may provide relief of nausea and vomiting

Advanced Interventions for Refractory Cases

Nutritional Support

• Enteral feeding via jejunostomy tube for patients with persistent symptoms and inadequate oral intake
• Bypasses the stomach to provide direct nutritional support
• Parenteral nutrition is rarely required 1, 3

Gastric Electrical Stimulation (GES)

• Option for patients with symptoms refractory to medical therapy
• May relieve symptoms including weekly vomiting frequency and reduce need for nutritional supplementation
• Approved under humanitarian device exemption 1, 3

Surgical Options (Rarely Used)

• Gastric emptying procedures (pyloroplasty)
• Partial gastrectomy
• Reserved for carefully selected patients who have failed all other treatments 1, 3

Special Considerations

Medication Management

• Avoid medications that worsen gastric emptying:
  • Opioids
  • Anticholinergics
  • Tricyclic antidepressants
  • GLP-1 receptor agonists 1

Diabetic Gastroparesis

• Careful regulation of glycemic control is essential
• DPP-4 inhibitors preferred over GLP-1 receptor agonists
• Insulin therapy with carefully titrated regimens may be considered 1

Monitoring

• Regular assessment of nutritional status
• Monitor for medication side effects, particularly with metoclopramide
• Electrolyte monitoring with persistent vomiting 1

Treatment Algorithm

1. Initial Management:

   • Dietary modifications + glycemic control (if diabetic)
   • Consider removing medications that delay gastric emptying

2. Mild-Moderate Symptoms:

   • Add prokinetic therapy (metoclopramide or erythromycin)
   • Add antiemetic agents as needed for symptom control

3. Refractory Symptoms:

   • Consider combination therapy with different classes of medications
   • Evaluate for gastric electrical stimulation
   • Consider enteral nutrition via jejunostomy if nutritional status compromised

4. Severe, Treatment-Resistant Cases:

   • Gastric electrical stimulation
   • Surgical interventions (rarely)

The treatment approach should be guided by symptom severity, nutritional status, and response to previous interventions, with careful attention to medication side effects and contraindications.