Treatment Recommendations for Severe Gastroparesis
For severe gastroparesis, a stepwise approach is recommended, starting with dietary modifications, prokinetic medications (metoclopramide as first-line), antiemetics for symptom control, and advancing to enteral nutrition via jejunostomy tube when oral intake is inadequate. 1
Dietary Management
- Implement 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 for sustained energy
- Avoid carbonated beverages, alcohol, and smoking
- Consider energy-dense liquid nutritional supplements 1
- Progress from solid food with modifications to blended/pureed foods if needed 1
Pharmacologic Management
First-Line Medications
- Metoclopramide: 10 mg orally, 30 minutes before meals and at bedtime (maximum 12 weeks due to risk of tardive dyskinesia) 2, 1
Alternative Prokinetic Agents
- Erythromycin: 40-250 mg orally 3 times daily 1
- Effective short-term but develops tachyphylaxis
- Concerns about antibiotic resistance with long-term use
Antiemetic Medications for Symptom Control
- 5-HT3 receptor antagonists:
- Ondansetron: 4-8 mg 2-3 times daily
- Granisetron: 1 mg twice daily or 34.3 mg patch weekly 3
- Phenothiazines:
- Prochlorperazine: 5-10 mg 4 times daily
- Chlorpromazine: 10-25 mg 3-4 times daily 3
- Antihistamines:
- Meclizine: 12.5-25 mg 3 times daily
- Scopolamine: 1.5 mg patch every 3 days 3
- NK-1 receptor antagonists:
- Aprepitant: 80 mg daily
- Tradipitant: 85 mg (shown to improve nausea especially in idiopathic gastroparesis) 3
Medications for Visceral Pain
- Tricyclic antidepressants:
- Amitriptyline: 25-100 mg daily
- Nortriptyline: 25-100 mg daily (secondary amines have fewer side effects) 3
- SNRIs:
- Duloxetine: 60-120 mg daily 3
- Anticonvulsants:
- Gabapentin: >1200 mg daily in divided doses
- Pregabalin: 100-300 mg daily in divided doses 3
Medications to Avoid or Minimize
- Opioids
- Anticholinergics
- Tricyclic antidepressants (when used for pain may worsen gastroparesis)
- GLP-1 receptor agonists
- Pramlintide 3, 1
Advanced Interventions for Severe Cases
Nutritional Support
- When oral intake is inadequate, consider enteral nutrition via jejunostomy tube 1, 4
- Parenteral nutrition is rarely required and should be reserved for cases where enteral nutrition fails 4
Device and Surgical Options
- Gastric electrical stimulation: Consider for medication-refractory symptoms 3, 1
- FDA-approved under Humanitarian Device Exemption
- May reduce weekly vomiting frequency and need for nutritional supplementation
- Venting gastrostomy: For symptomatic relief in severe cases 4
- Surgical interventions (partial gastrectomy, pyloroplasty): Reserved for carefully selected patients who have failed all other therapies 4
Special Considerations for Diabetic Gastroparesis
- Optimize glycemic control
- Consider DPP-4 inhibitors which have neutral effect on gastric emptying 1
- Insulin therapy with appropriate dose adjustments 1
- Regular monitoring of nutritional status and electrolyte levels 1
Monitoring
- Assess nutritional status regularly
- Monitor for medication side effects, particularly with metoclopramide
- In diabetic patients, monitor glycemic control
- Evaluate treatment response based on symptom improvement and quality of life 1
Severe gastroparesis requires aggressive management with close monitoring. The treatment approach should progress from less invasive to more invasive options as symptoms dictate, with the primary goals of improving symptoms, maintaining nutrition, and enhancing quality of life.