What are the treatment options for gastro paresis?

Gastroparesis Treatment Options

The first-line treatment for gastroparesis is dietary modification combined with metoclopramide (10 mg orally, 30 minutes before meals and at bedtime) as the primary prokinetic agent, though its use should be limited to 12 weeks due to risk of tardive dyskinesia. 1

Treatment Algorithm

Step 1: Dietary Modifications

• Implement low-fiber, low-fat diet with small, frequent meals (5-6 per day)
• Increase proportion of liquid calories
• Focus on foods with small particle size to facilitate gastric emptying
• Follow a stepwise nutritional approach:
  • Start with modified solid foods
  • Progress to blended/pureed foods if needed
  • Consider liquid diet with oral nutritional supplements for more severe cases
  • For severe refractory cases, consider enteral nutrition via jejunostomy tube 1

Step 2: Optimize Glycemic Control (for Diabetic Gastroparesis)

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

Step 3: Pharmacological Treatment

First-Line Prokinetic Agents:

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

  • Limit use to 12 weeks due to risk of tardive dyskinesia
  • For severe symptoms, may begin with injectable form (IM or IV) before transitioning to oral 1, 2
  • Reduce dose by approximately half in patients with creatinine clearance below 40 mL/min 2

• Erythromycin: 40-250 mg orally 3 times daily

  • Alternative first-line prokinetic
  • Effectiveness may diminish over time due to tachyphylaxis 1

Antiemetic Agents for Symptom Control:

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

Other Pharmacological Options:

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

  • Advantage: Fewer central side effects than metoclopramide
  • Caution: Requires cardiac monitoring due to QT prolongation risk 1
  • Note: The AGA issued a conditional recommendation against domperidone as first-line therapy 3

• Somatostatin analogue (octreotide)

  • Consider for refractory cases, especially in systemic sclerosis
  • May be more effective when combined with erythromycin 1

Step 4: Interventional Approaches for Refractory Cases

• Gastric electrical stimulation (GES)

  • FDA-approved for treating refractory gastroparesis
  • Most effective for patients with predominant nausea and vomiting
  • Best for diabetic or idiopathic gastroparesis
  • Contraindicated in patients with predominant abdominal pain, current opioid use, or very prolonged symptoms 1
  • AGA recommends reserving this for select patients with symptoms refractory to medical therapies 3

• Gastric peroral endoscopic myotomy (G-POEM)

  • Consider for patients with severe delay in gastric emptying
  • AGA recommends reserving this for select patients with symptoms refractory to medical therapies 1, 3

• Botulinum toxin injection into the pylorus

  • Limited evidence for effectiveness 1

• Surgical options (for carefully selected patients only)

  • Venting gastrostomy
  • Feeding jejunostomy
  • Partial gastrectomy and pyloroplasty (rarely used) 1, 4

Important Considerations and Pitfalls

• Diagnosis confirmation: Ensure proper diagnosis using 4-hour gastric emptying scintigraphy (>10% retention at 4 hours) before initiating treatment 1, 3

• Metoclopramide safety: Monitor closely for extrapyramidal symptoms and tardive dyskinesia. If acute dystonic reactions occur, inject 50 mg diphenhydramine hydrochloride intramuscularly 2

• Medication-related gastroparesis: Review and adjust current medications that may delay gastric emptying 5

• Symptom-directed approach: Identify dominant symptoms (fullness, nausea, abdominal pain, heartburn) to better direct management efforts 6

• Refractory cases: Consider combination therapy with both prokinetic and antiemetic agents before moving to interventional approaches 5, 4

• Nutritional monitoring: Regularly assess nutritional status and adjust treatment approach if oral intake remains inadequate 1, 4

The management of gastroparesis remains challenging, with many patients requiring multiple approaches to achieve symptom control. While metoclopramide and erythromycin remain the mainstays of pharmacological treatment, ongoing research into newer agents like ghrelin receptor agonists, serotonergic agents, and NK-1 receptor antagonists may provide additional options in the future 1.