What are the considerations for using Ozempic (semaglutide) in patients with recurrent gastroparesis?

Ozempic (Semaglutide) is Contraindicated in Patients with Recurrent Gastroparesis

Semaglutide should not be used in patients with a history of recurrent gastroparesis as it can significantly worsen gastric emptying delay and exacerbate gastroparesis symptoms. 1

Mechanism of Concern

Semaglutide, a GLP-1 receptor agonist, works by:

• Slowing gastric emptying as part of its mechanism of action
• Potentially aggravating existing gastroparesis pathophysiology
• Worsening symptoms such as nausea, vomiting, bloating, and abdominal pain

Gastroparesis Management Considerations

Assessment of Gastroparesis Severity

Patients with recurrent gastroparesis should be classified based on 2:

• Symptom severity (mild, moderate, severe)
• Gastric emptying study results (degree of emptying delay)
• Predominant symptom pattern (nausea/vomiting vs. pain)

First-Line Treatment Options

1. Dietary modifications 3:

   • Small, frequent meals (5-6 per day)
   • Low fat and fiber content
   • Increased liquid calories
   • Complex carbohydrates for sustained energy
   • Avoidance of carbonated beverages, alcohol, and smoking

2. Prokinetic medications 3:

   • Metoclopramide: 10 mg orally, 30 minutes before meals and at bedtime (FDA-approved)
   • Erythromycin: 40-250 mg orally 3 times daily (alternative first-line)

3. Antiemetic agents for symptom control 3:

   • 5-HT3 receptor antagonists (ondansetron 4-8 mg 2-3 times daily)
   • Phenothiazines (prochlorperazine 5-10 mg 4 times daily)
   • Antihistamines (meclizine 12.5-25 mg 3 times daily)

Pain Management in Gastroparesis

For patients with predominant pain 2:

• Tricyclic antidepressants (amitriptyline 25-100 mg daily)
• SNRIs (duloxetine 60-120 mg daily)
• Anticonvulsants (gabapentin >1200 mg daily in divided doses)
• Avoid opioids as they further delay gastric emptying

Refractory Gastroparesis Options

For patients with medically refractory gastroparesis 2, 4:

1. Gastric electrical stimulation (GES):

   • Consider for patients with refractory/intractable nausea and vomiting
   • Most effective for reducing weekly vomiting frequency
   • Requires surgical implantation
   • System replacement at different gastric location may be considered if initial GES fails 5

2. Gastric peroral endoscopic myotomy (G-POEM) 2:

   • Consider for patients with severe delay in gastric emptying
   • Most appropriate for those with moderate-to-severe symptoms
   • Best for patients with nausea and vomiting as dominant symptoms
   • Requires a center of excellence with motility specialists and advanced endoscopists

3. Nutritional support 3, 6:

   • Enteral nutrition via jejunostomy tube when oral intake is inadequate
   • Parenteral nutrition rarely required

Clinical Pitfalls and Caveats

1. Medication interactions:

   • GLP-1 receptor agonists like semaglutide can significantly worsen gastroparesis symptoms
   • Opioids should be avoided as they delay gastric emptying
   • Anticholinergic medications can worsen symptoms

2. Diagnostic considerations:

   • Ensure proper methodology of gastric emptying study (abnormal if >10% retention at 4 hours)
   • Exclude mechanical obstruction with endoscopy
   • Symptoms alone are insufficient for diagnosis

3. Treatment monitoring:

   • Regular assessment of nutritional status and electrolytes
   • Monitor for medication side effects
   • Consider multivitamin supplementation to prevent deficiencies

Special Considerations for Diabetic Patients

For diabetic patients with gastroparesis 3:

• Optimize glycemic control
• Consider DPP-4 inhibitors which have neutral effects on gastric emptying
• Adjust insulin therapy as needed
• Avoid GLP-1 receptor agonists like semaglutide

In conclusion, the management of recurrent gastroparesis requires a systematic approach focusing on symptom control and improving gastric emptying. Semaglutide should be avoided in these patients due to its mechanism of action that further delays gastric emptying.