What are the treatment options for gastro paresis?

Treatment Options for Gastroparesis

The first-line treatment for gastroparesis includes dietary modifications, prokinetic medications (primarily metoclopramide), and symptom management with antiemetics, with more advanced interventions such as gastric electrical stimulation reserved for refractory cases. 1

Non-Pharmacological Management

Dietary Modifications

• Low-fiber, low-fat diet with small, frequent meals (5-6 per day) is the cornerstone of non-pharmacological management 1
• Implement a stepwise nutritional approach:
  1. Modified solid foods (small particle size)
  2. Increase proportion of liquid calories
  3. Blended/pureed foods
  4. Liquid diet with oral nutritional supplements
  5. Consider enteral nutrition via jejunostomy tube for severe cases 1

Pharmacological Treatment

Prokinetic Agents

• Metoclopramide (10 mg orally, 30 minutes before meals and at bedtime)

  • First-line prokinetic therapy for diabetic gastroparesis 1
  • Limited to 12 weeks due to risk of tardive dyskinesia 1, 2
  • For patients with renal impairment (creatinine clearance <40 mL/min), start at approximately half the recommended dose 2

• Erythromycin (40-250 mg orally 3 times daily)

  • Alternative prokinetic therapy
  • Effectiveness diminishes over time due to tachyphylaxis 1

• Domperidone (if available, 10 mg three times daily)

  • Advantage: Fewer central side effects than metoclopramide
  • Caution: Requires cardiac monitoring due to QT prolongation risk 1

Antiemetic Medications

For symptom control in patients with severe gastroparesis: 1

• Phenothiazines
• Trimethobenzamide
• Serotonin (5-HT3) receptor antagonists (ondansetron, granisetron)
• NK-1 receptor antagonists (aprepitant)
• Tricyclic antidepressants
• SNRIs
• Anticonvulsants

Other Pharmacological Options

• Somatostatin analogue (octreotide) may be beneficial, especially in systemic sclerosis when other treatments have failed 1
• Prucalopride (1 mg daily in severe renal impairment) - a selective 5-HT4 receptor agonist that enhances GI motility 1

Advanced Interventions for Refractory Cases

Surgical and Endoscopic Options

• Gastric electrical stimulation (GES)

  • FDA-approved for treating refractory gastroparesis
  • Significantly improves nausea and vomiting symptoms
  • Best for patients with diabetic or idiopathic gastroparesis with predominant nausea and vomiting 1, 3
  • Contraindications: predominant abdominal pain, current opioid use, very prolonged symptoms 1

• Gastric peroral endoscopic myotomy (G-POEM)

  • Consider for patients with severe delay in gastric emptying 1

• Enteral nutrition via jejunostomy tube

  • For patients with severe gastroparesis when oral intake is inadequate 1, 3

• Botulinum toxin injection into the pylorus

  • Limited evidence of effectiveness in randomized controlled trials 1, 3

Special Considerations for Diabetic Gastroparesis

Glycemic Control

• Achieve near-normal glycemic control to prevent progression 1
• Adjust insulin timing and dosage to account for delayed gastric emptying 1, 2
• Consider DPP-4 inhibitors which have a neutral effect on gastric emptying 1

Common Pitfalls and Caveats

1. Metoclopramide safety concerns:

   • Risk of tardive dyskinesia increases with higher doses and longer duration
   • Geriatric patients should receive the lowest effective dose 2
   • Monitor for extrapyramidal symptoms, especially in pediatric and elderly populations 2

2. Drug interactions:

   • Metoclopramide effects are antagonized by anticholinergics and narcotic analgesics 2
   • Additive sedative effects with alcohol, sedatives, hypnotics, narcotics, or tranquilizers 2
   • May affect absorption of other medications (diminished for drugs from stomach, increased for drugs from small bowel) 2

3. Insulin management:

   • Gastroparesis may cause poor diabetic control
   • Exogenous insulin may act before food leaves the stomach, leading to hypoglycemia
   • Insulin dosage or timing may require adjustment 2

4. Treatment resistance:

   • Consider combination therapy if monotherapy is ineffective 4
   • Partial gastrectomy and pyloroplasty should be used rarely and only in carefully selected patients 3

5. Patient selection for advanced interventions:

   • Identify the dominant symptoms (fullness, nausea, abdominal pain) to direct management efforts 5
   • A subset of patients with diabetic gastroparesis have pylorospasm that results in obstructive gastroparesis, which may respond differently to treatments 6