What are the treatment options for gastroparesis?

Treatment Options for Gastroparesis

The management of gastroparesis should follow a stepwise approach beginning with dietary modifications, prokinetic medications like metoclopramide as first-line therapy, symptom-targeted medications, and advancing to interventional therapies for refractory cases. 1

Dietary and Nutritional Management

• Initial dietary modifications:

  • Low-fat, low-fiber diet with small, frequent meals (5-6 per day) 1
  • Increase liquid calories and foods with small particle size 1
  • Avoid carbonated beverages, alcohol, and smoking 1

• Stepwise nutritional approach:

  1. Modified solid foods
  2. Blended/pureed foods
  3. Liquid diet with oral nutritional supplements
  4. Enteral nutrition via jejunostomy tube for severe cases 1

Pharmacological Management

Prokinetic Agents

1. Metoclopramide (First-line therapy)

   • Dosing: 10 mg orally 30 minutes before meals and at bedtime 1, 2
   • Limitations: Use limited to 12 weeks due to risk of tardive dyskinesia 1
   • For severe symptoms: Initial IV administration may be required before transitioning to oral therapy 2
   • Dose reduction: For patients with creatinine clearance <40 mL/min, start at half the recommended dose 2

2. Erythromycin (Alternative first-line)

   • Dosing: 40-250 mg orally 3 times daily 1
   • Limitation: Effectiveness diminishes over time due to tachyphylaxis 1

Antiemetic Agents for Symptom Control

• Phenothiazines
• Trimethobenzamide
• Serotonin (5-HT3) receptor antagonists
• NK-1 receptor antagonists 1

Medications to Avoid or Use with Caution

• GLP-1 receptor agonists (should be withdrawn) 1
• Pramlintide
• Anticholinergics
• Tricyclic antidepressants (though may be used as antiemetics in some cases)
• Opioids 1

Interventional Therapies for Refractory Cases

1. Gastric electrical stimulation (GES)

   • Effective for reducing vomiting frequency in medically refractory cases 1

2. Gastric peroral endoscopic myotomy (G-POEM)

   • Consider for patients with severe delay in gastric emptying 1

3. Enteral feeding options

   • Jejunostomy tube placement when oral intake is inadequate 1, 3
   • Venting gastrostomy for symptomatic relief 3

4. Botulinum toxin injection into the pylorus

   • Limited evidence for effectiveness 1

5. Surgical options (rare, last resort)

   • Partial gastrectomy and pyloroplasty only in carefully selected patients 3

Special Considerations for Diabetic Gastroparesis

• Optimize glycemic control 1
• Consider DPP-4 inhibitors which have neutral effect on gastric emptying 1
• Sulfonylureas and thiazolidinediones (TZDs) also have neutral effects on gastric motility 1

Monitoring and Follow-up

• Regular assessment of:
  • Nutritional status and electrolytes
  • Medication side effects (particularly extrapyramidal symptoms)
  • Glycemic control in diabetic patients 1

Common Pitfalls and Caveats

1. Medication-related pitfalls:

   • Failure to recognize tardive dyskinesia with metoclopramide
   • Continuing GLP-1 receptor agonists which can worsen gastroparesis
   • Tachyphylaxis with erythromycin limiting long-term effectiveness

2. Nutritional pitfalls:

   • Inadequate monitoring of nutritional status leading to malnutrition
   • Delayed recognition of need for enteral nutrition support

3. Management pitfalls:

   • Overreliance on medications without adequate dietary modifications
   • Failure to adjust diabetes medications that affect gastric motility
   • Delayed consideration of interventional therapies in refractory cases

The treatment of gastroparesis requires a structured approach that addresses both symptom management and underlying gastric dysmotility, with careful monitoring for medication side effects and nutritional status.