Is there evidence for using domperidone (Antiemetic and Prokinetic agent) for Avoidant/Restrictive Food Intake Disorder (ARFID)?

No Evidence Supports Domperidone Use for ARFID

There is no evidence supporting the use of domperidone for Avoidant/Restrictive Food Intake Disorder (ARFID), and its potential cardiac risks outweigh any theoretical benefits.

Understanding ARFID and Its Treatment Approach

ARFID is a feeding disorder characterized by:

• Abnormal eating or feeding behaviors resulting in insufficient food intake
• Significant weight loss, nutritional deficiencies, or interference with psychosocial functioning
• Absence of body image distortion or fear of weight gain (distinguishing it from anorexia nervosa)

ARFID typically presents in three main patterns 1:

• Sensory-based avoidance
• Fear-based avoidance
• Lack of interest in food/eating

Evidence-Based Treatment Recommendations for ARFID

The recommended treatment approach for ARFID is multidisciplinary and includes:

1. Psychological interventions:

   • Cognitive behavioral therapy with graded exposure therapy is the optimal approach 1
   • Family-based treatment for children and adolescents 2

2. Nutritional rehabilitation:

   • Careful nutritional management without reinforcing avoidance 1
   • Avoidance of parenteral nutrition except in life-threatening cases 1

3. Assessment for comorbidities:

   • Screening for anxiety disorders and other psychiatric conditions 3
   • Evaluation for gastrointestinal disorders and functional dyspepsia 1

Domperidone: Lack of Evidence for ARFID

There is no specific evidence supporting domperidone use for ARFID in any of the available guidelines or research. The British Society of Gastroenterology guidelines mention ARFID in the context of functional dyspepsia (FD), recommending assessment for ARFID in patients with severe or refractory FD presenting with weight loss and food restriction 4, but do not recommend domperidone for ARFID.

Prokinetic Agents in Related Conditions

While prokinetic agents like domperidone are sometimes used for gastrointestinal motility disorders:

1. Cancer-related early satiety: The ESPEN guideline suggests considering prokinetic agents for early satiety in cancer patients, but warns about potential adverse effects of domperidone on cardiac rhythm 4.

2. Systemic sclerosis: In SSc patients with gastrointestinal involvement, domperidone has shown some improvement in GERD symptoms, but 17% of patients did not respond to this therapy 4.

Safety Concerns with Domperidone

Domperidone carries significant safety concerns:

• Cardiac risks: Domperidone has been associated with increased risk of sudden cardiac death with a low safety index 5
• Limited efficacy: In healthy adults, acute administration of domperidone did not change gastric emptying or appetite sensations following a high-fat test meal 6
• Regulatory status: Due to cardiac safety concerns, domperidone has restricted availability in many countries 7

Conclusion for Clinical Practice

For ARFID management, clinicians should:

1. Focus on evidence-based approaches including cognitive behavioral therapy with graded exposure and family-based treatment
2. Address nutritional needs without reinforcing avoidance behaviors
3. Screen for and manage comorbid conditions
4. Avoid medications like domperidone that lack evidence for ARFID and carry significant safety risks

Given the lack of evidence for efficacy and the known cardiac risks, domperidone should not be used for ARFID treatment.