What is the treatment for gastroparesis?

Treatment for Gastroparesis

The management of gastroparesis should begin with dietary modifications, followed by metoclopramide as first-line pharmacological therapy, with alternative medications, gastric electrical stimulation, and nutritional support considered for refractory cases. 1

Dietary Management

• Recommend small, frequent meals (5-6 per day) that are low in fat and fiber
• Increase liquid calories and foods with small particle size
• Focus on complex carbohydrates and energy-dense liquids
• Advise patients to avoid:
  • Carbonated beverages
  • Alcohol
  • Smoking
• Early dietitian involvement is strongly recommended, especially for severe cases 1

Pharmacological Management

First-Line Medications

• Metoclopramide: 10 mg orally, 30 minutes before meals and at bedtime
  • Only FDA-approved medication for gastroparesis
  • Limited to 12 weeks due to risk of tardive dyskinesia
  • For severe symptoms, may begin with injectable form (IM or IV) before transitioning to oral 1, 2

Alternative Prokinetics

• Erythromycin: 40-250 mg orally 3 times daily
  • Effective alternative but limited by tachyphylaxis with long-term use 1

Antiemetics for Symptom Control

• Ondansetron: 4-8 mg 2-3 times daily
• Prochlorperazine: 5-10 mg 4 times daily
• Trimethobenzamide: 300 mg 3 times daily 1

Medications to Avoid

• Opioids
• Anticholinergics
• Tricyclic antidepressants
• GLP-1 receptor agonists
• Pramlintide 1

Management in Special Populations

Diabetic Gastroparesis

• Withdraw medications that adversely affect GI motility, including GLP-1 RAs
• Consider DPP-4 inhibitors for glucose control (neutral effect on gastric emptying)
• Insulin therapy remains an option with appropriate dose adjustments
• Metformin or SGLT-2 inhibitors may be considered if not contraindicated 1

Advanced Interventions for Refractory Cases

Nutritional Support (Stepwise Approach)

1. Modified solid food diet
2. Blended or pureed foods
3. Liquid diet with oral nutritional supplements
4. Enteral nutrition via jejunostomy tube
5. Parenteral nutrition (last resort) 1, 3

Gastric Electrical Stimulation

• Consider for medication-refractory symptoms
• May relieve symptoms including weekly vomiting frequency
• Can reduce need for nutritional supplementation 1, 3

Surgical Options

• Gastric emptying procedures (e.g., pyloroplasty)
• Total gastrectomy in rare cases where all other treatments have failed 1

Monitoring and Follow-up

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

Common Pitfalls and Caveats

• Metoclopramide should be used with caution due to risk of tardive dyskinesia; limit to 12 weeks when possible
• Erythromycin effectiveness decreases over time due to tachyphylaxis
• Overly restrictive diets can worsen nutritional deficiencies
• Patients with renal impairment should receive approximately half the recommended metoclopramide dosage 1, 2
• Young female patients have higher prevalence of idiopathic gastroparesis and may have psychological factors contributing to symptoms 1