What are the treatment options for gastroparesis?

Treatment Options for Gastroparesis

The first-line treatment for gastroparesis is metoclopramide at a dose of 10 mg orally, 30 minutes before meals and at bedtime, as it is the only FDA-approved medication for this condition. 1

Pharmacological Management

Prokinetic Agents

• Metoclopramide: 10 mg orally, 30 minutes before meals and at bedtime 1, 2

  • FDA-approved specifically for gastroparesis
  • Limited to 12 weeks of use due to risk of tardive dyskinesia
  • For severe symptoms, may begin with injectable form before transitioning to oral 2

• Erythromycin: 40-250 mg orally 3 times daily 1

  • Alternative first-line agent
  • Limitations include antibiotic resistance and tachyphylaxis (diminishing response with continued use)

Antiemetic Medications

1. 5-HT3 receptor antagonists:

   • Ondansetron: 4-8 mg 2-3 times daily
   • Granisetron: 1 mg twice daily or 34.3 mg patch weekly 1

2. Phenothiazines:

   • Prochlorperazine: 5-10 mg 4 times daily
   • Chlorpromazine: 10-25 mg 3-4 times daily 1

3. Antihistamines:

   • Meclizine: 12.5-25 mg 3 times daily
   • Scopolamine: 1.5 mg patch every 3 days 1

4. NK-1 receptor antagonists:

   • Aprepitant: 80 mg daily
   • Tradipitant: 85 mg daily (particularly effective for nausea in idiopathic gastroparesis) 1

Neuromodulators for Pain and Symptom Control

• Tricyclic antidepressants:

  • Amitriptyline: 25-100 mg daily
  • Nortriptyline: 25-100 mg daily (secondary amines have fewer side effects) 1

• SNRIs:

  • Duloxetine: 60-120 mg daily 1

• Anticonvulsants:

  • Gabapentin: >1200 mg daily in divided doses
  • Pregabalin: 100-300 mg daily in divided doses 1

Nutritional and Dietary Management

Dietary Modifications

• Eat small, frequent meals (5-6 per day) that are low in fat and fiber 1
• 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 liquids for easier digestion 1

Stepwise Nutritional Approach

1. Start with solid food with modifications
2. Progress to blended/pureed foods if needed
3. Transition to liquid diet with oral nutritional supplements
4. Consider enteral nutrition via jejunostomy tube for severe cases 1

Interventional Therapies

• Gastric electrical stimulation: Consider for medication-refractory symptoms

  • Goals: Reduce weekly vomiting frequency and need for nutritional supplementation 1
  • Based on moderate strength of evidence from clinical trials

• Enteral feeding: Via jejunostomy tube when oral intake is inadequate 1, 3

• Venting gastrostomy: Second-line approach for symptom relief 3

Management of Comorbid Conditions

Diabetes Management

• Optimize glycemic control 1
• Consider DPP-4 inhibitors (neutral effect on gastric emptying) 1
• Insulin therapy with appropriate dose adjustments 1
• Consider metformin or SGLT-2 inhibitors if not contraindicated 1
• Avoid GLP-1 receptor agonists and pramlintide as they can worsen gastroparesis 1

Medications to Avoid or Minimize

• Opioids
• Anticholinergics
• Tricyclic antidepressants (when used for other conditions)
• GLP-1 receptor agonists
• Pramlintide
• Possibly dipeptidyl peptidase 4 inhibitors 1

Monitoring and Follow-up

• Monitor electrolytes, especially with persistent vomiting 1
• Consider multivitamin supplementation to prevent nutritional deficiencies 1
• For severe cases requiring hospitalization, provide:
  • IV hydration
  • Electrolyte replacement
  • Vitamin supplementation
  • Parenteral nutrition if necessary 1

Special Considerations

• Renal or hepatic impairment: For patients with creatinine clearance below 40 mL/min, initiate metoclopramide at approximately half the recommended dosage 2

• Acute dystonic reactions: If they occur with metoclopramide, inject 50 mg diphenhydramine hydrochloride intramuscularly 2

Important Caveats

• Diagnosis must be confirmed with gastric emptying scintigraphy, not based solely on symptoms 1
• Gastric emptying scintigraphy is considered abnormal if >10% retention at 4 hours 1
• Partial gastrectomy and pyloroplasty should be used rarely and only in carefully selected patients 3
• Intrapyloric botulinum toxin injection has not been shown to be effective in randomized controlled trials 3