What is the treatment for a gastroparesis flare-up?

Treatment for Gastroparesis Flare-Up

For gastroparesis flare-ups, implement a stepwise approach starting with dietary modifications (small, frequent, low-fiber, low-fat meals with increased liquid calories), followed by metoclopramide 10 mg orally 30 minutes before meals and at bedtime as first-line pharmacological therapy. 1

Immediate Dietary Interventions

• Switch to a low-fiber, low-fat diet with small, frequent meals (5-6 per day)
• Increase proportion of liquid calories and foods with small particle size
• Progress through dietary modifications based on symptom severity:
  1. Modified solid foods →
  2. Blended/pureed foods →
  3. Liquid diet with oral nutritional supplements →
  4. Consider enteral nutrition via jejunostomy tube for severe cases 1

Medication Management

First-Line Prokinetic Therapy

• Metoclopramide 10 mg orally, 30 minutes before meals and at bedtime 1, 2
  • FDA-approved for relief of symptoms associated with acute and recurrent diabetic gastric stasis 2
  • Limit use to 12 weeks due to risk of tardive dyskinesia 1
  • For severe symptoms, may initiate with injectable form (IM or IV) before transitioning to oral 2
  • Reduce dose by approximately half in patients with creatinine clearance below 40 mL/min 2

Alternative Prokinetic Therapy

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

Antiemetic Agents for Symptom Control

• Options include:
  • Phenothiazines
  • Trimethobenzamide
  • Serotonin (5-HT3) receptor antagonists
  • NK-1 receptor antagonists
  • Tricyclic antidepressants (at lower doses for symptom control) 1

Important Management Steps

Medication Adjustments

• Withdraw medications that delay gastric emptying:
  • GLP-1 receptor agonists
  • Pramlintide
  • Opioids
  • Anticholinergics
  • Tricyclic antidepressants (when used at higher doses) 1

Glycemic Control (for Diabetic Gastroparesis)

• Achieve near-normal glycemic control to prevent progression
• Consider DPP-4 inhibitors which have a neutral effect on gastric emptying 1
• Adjust insulin timing and dosage to account for delayed gastric emptying

Advanced Interventions for Refractory Cases

• Gastric electrical stimulation (GES) for patients with:

  • Medically refractory gastroparesis
  • Predominant symptoms of nausea and vomiting
  • Not dependent on opioid medications 1

• Consider gastric peroral endoscopic myotomy (G-POEM) for patients with severe delay in gastric emptying 1

Common Pitfalls and Caveats

• Metoclopramide has significant risk of tardive dyskinesia with prolonged use (>12 weeks)
• Erythromycin effectiveness decreases over time due to tachyphylaxis
• Combination therapy (e.g., metoclopramide with erythromycin) may be beneficial for refractory cases but has limited evidence 3
• Avoid opioids as they can worsen gastroparesis symptoms
• Botulinum toxin injection into the pylorus has limited evidence for effectiveness 1
• Total gastrectomy should only be considered as a last resort for end-stage gastroparesis when all other therapies have failed 3

Monitoring and Follow-up

• Assess response to dietary modifications and medications
• Monitor for side effects of medications, particularly extrapyramidal symptoms with metoclopramide
• Evaluate nutritional status regularly
• For diabetic patients, monitor glycemic control closely