What are the treatment options for gastroparesis?

Treatment Options for Gastroparesis

The management of gastroparesis should include dietary modifications, prokinetic agents (with metoclopramide as first-line therapy), antiemetics for symptom control, and interventional therapies for refractory cases. 1

Dietary Modifications

• Low-fat, low-fiber diet with emphasis on:

  • Small, frequent meals (5-6 per day)
  • Increased liquid calories
  • Foods with small particle size
  • Complex carbohydrates
  • Avoiding 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, 2

Pharmacological Management

Prokinetic Agents

1. First-line: Metoclopramide

   • Dosing: 10 mg orally 30 minutes before meals and at bedtime
   • Limitations: Use limited to 12 weeks due to risk of tardive dyskinesia
   • For severe symptoms, may initiate with injectable form (IM or IV) before transitioning to oral 1, 3
   • For patients with renal impairment (creatinine clearance <40 mL/min), start at half the recommended dose 3

2. Alternative: Erythromycin

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

3. Other options:

   • Prucalopride: A selective 5-HT4 receptor agonist (1 mg daily in severe renal impairment) 1
   • Domperidone: Not FDA-approved in US but used in other countries 2, 4

Antiemetic Agents

• Options include:
  • Phenothiazines
  • Trimethobenzamide
  • Serotonin (5-HT3) receptor antagonists (ondansetron, granisetron)
  • NK-1 receptor antagonists
  • Tricyclic antidepressants (used as symptom modulators)
  • SNRIs
  • Anticonvulsants 1, 2

Medications to Avoid or Use with Caution

• GLP-1 receptor agonists (should be withdrawn)
• Pramlintide
• Anticholinergics
• Tricyclic antidepressants (despite potential benefit, use cautiously)
• Opioids 1

Interventional Therapies for Refractory Cases

1. Gastric Electrical Stimulation (GES)

   • Effective for reducing vomiting frequency in medically refractory cases
   • FDA-approved under humanitarian device exemption 1, 2, 5

2. Gastric Peroral Endoscopic Myotomy (G-POEM)

   • Consider for patients with severe delay in gastric emptying
   • Evidence level: Low 1

3. Enteral Nutrition

   • Jejunostomy tube feeding when oral intake is inadequate
   • Evidence level: Moderate 1, 2

4. Other Options

   • Botulinum toxin injection into the pylorus (limited evidence) 1, 6
   • Venting gastrostomy (for symptom relief) 2
   • Partial gastrectomy and pyloroplasty (rarely used, only in carefully selected patients) 2

Special Considerations

Diabetic Gastroparesis

• Optimize glycemic control
• Medication preferences:
  • DPP-4 inhibitors have neutral effect on gastric emptying
  • Sulfonylureas and thiazolidinediones (TZDs) also have neutral effect 1

Monitoring

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

Treatment Algorithm

1. Initial Management:

   • Dietary modifications
   • Optimize glycemic control (if diabetic)
   • Withdraw medications that delay gastric emptying

2. Mild Symptoms:

   • Metoclopramide 10 mg before meals and at bedtime
   • Add antiemetics as needed for symptom control

3. Persistent Symptoms:

   • Consider alternative prokinetics (erythromycin)
   • Combination therapy with different mechanisms of action

4. Refractory Symptoms:

   • Consider nutritional support via jejunostomy tube
   • Evaluate for gastric electrical stimulation
   • Consider G-POEM or other interventional approaches

Common Pitfalls and Caveats

• Metoclopramide safety: Monitor closely for extrapyramidal symptoms and limit use to 12 weeks due to risk of tardive dyskinesia 1, 3
• Tachyphylaxis with erythromycin: Effectiveness may diminish over time 1
• Nutritional deficiencies: Patients with gastroparesis are at high risk; regular monitoring is essential 1
• Medication interactions: Be aware of potential QT prolongation with multiple antiemetics or prokinetics 2
• Realistic expectations: Complete symptom resolution may not be achievable; focus on improving quality of life and maintaining nutrition 2, 6