From the Guidelines
Gastroparesis treatment should prioritize dietary modifications and medication adjustments, with metoclopramide reserved for severe cases due to its potential for serious adverse effects, as recommended by the most recent guidelines 1.
Treatment Approach
The primary goal of gastroparesis treatment is to manage symptoms, improve gastric emptying, and maintain nutrition.
- Dietary modifications are the first-line approach, including eating smaller, more frequent meals, low-fat and low-fiber foods, and avoiding carbonated beverages.
- Medications that slow gastric emptying, such as opioids, anticholinergics, and GLP-1 RAs, should be discontinued if possible, weighing the benefits against the risks, especially for GLP-1 RAs 1.
Medication Options
For symptom management:
- Metoclopramide (5-10mg before meals and at bedtime) is the primary prokinetic agent, though its use beyond 12 weeks is not recommended due to the risk of serious adverse effects, such as extrapyramidal signs and tardive dyskinesia 1.
- Alternative prokinetics include erythromycin (50-125mg before meals), which is effective for short-term use due to tachyphylaxis, and domperidone (10mg before meals), available outside the U.S. 1.
- Antiemetics like ondansetron or prochlorperazine can help control nausea and vomiting.
Invasive Options
For refractory cases, more invasive options include:
- Gastric electrical stimulation using a surgically implantable device, which has received FDA approval but has variable efficacy and is limited to individuals with severe symptoms refractory to other treatments 1.
- Pyloromyotomy or feeding tubes (jejunostomy) to bypass the stomach may be considered in severe cases. Regular monitoring of nutritional status and medication side effects is essential for optimal management, prioritizing the patient's quality of life and minimizing morbidity and mortality risks 1.
From the FDA Drug Label
For the Relief of Symptoms Associated with Diabetic Gastroparesis (Diabetic Gastric Stasis) If only the earliest manifestations of diabetic gastric stasis are present, oral administration of metoclopramide may be initiated. However, if severe symptoms are present, therapy should begin with metoclopramide injection (IM or IV)
The treatment options for Gastroparesis include:
- Oral administration of metoclopramide for early manifestations of diabetic gastric stasis
- Intramuscular (IM) or intravenous (IV) injection of metoclopramide for severe symptoms Key considerations:
- The choice of treatment depends on the severity of symptoms
- Metoclopramide may be initiated orally for mild symptoms, but severe symptoms require IM or IV administration 2
From the Research
Treatment Options for Gastroparesis
The treatment options for gastroparesis include:
- Dietary modifications
- Medication adjustments
- Glucose control
- Antiemetic agents
- Prokinetic agents such as metoclopramide, domperidone, and erythromycin 3, 4, 5
- Mechanical therapies such as endoscopic pyloric botulinum toxin injection, gastric electrical stimulation, and gastrostomy or jejunostomy 3, 6
- Novel investigational motilin receptor and ghrelin agonists, such as mitemcinal and TZP-101 3
- Recent advanced endoscopic and surgical therapies, including endoscopic pyloromyotomy 6, 7
- Fundic relaxants such as acotiamide and buspirone 7
Pharmacological Treatment
Pharmacological treatment for gastroparesis may involve the co-administration of several classes of drugs, which can lead to potential drug-drug interactions (DDIs) 4.
- Prokinetic agents such as metoclopramide and domperidone are the cornerstone in treatment of gastroparesis
- Antiemetic agents such as promethazine and ondansetron are frequently administered to gastroparesis patients to reduce nausea and vomiting
- Antidiabetic agents are also prescribed for diabetic patients with gastroparesis
Refractory Symptoms
Treatments for refractory symptoms may include:
- Gastric electric stimulation
- Intra-pyloric interventions like botulinum toxin and endoscopic pyloromyotomy 6