What are the treatment options for gastroparesis?

Treatment Options for Gastroparesis

The primary treatment approach for gastroparesis includes dietary modifications, antiemetic medications, and prokinetic agents, with more advanced interventions reserved for refractory cases. 1

Dietary Management

• Eat frequent smaller meals and replace solid foods with liquids (such as soups) 1
• Follow a low-fat, low-fiber diet to improve gastric emptying 1
• Foods with smaller particle size may improve key symptoms 1
• Liquid nutritional supplements should be considered if oral intake is inadequate 2

Pharmacologic Treatment

Antiemetic Medications

• Antiemetic agents are used primarily for nausea and vomiting symptoms 1
• Common antiemetic classes include:
  • Antidopaminergics (prochlorperazine, trimethobenzamide, promethazine) 1
  • Antihistamines 1
  • Anticholinergics 1
  • Serotonin (5-HT3) receptor antagonists - best used on an as-needed basis 1

Prokinetic Medications

• Metoclopramide is the only FDA-approved prokinetic agent for gastroparesis in the US 1
  • Initial dosing is typically 10 mg orally before meals 3
  • FDA limits use to 12 weeks due to risk of serious neurological side effects (extrapyramidal symptoms, tardive dyskinesia) 1
  • Should be reserved for severe cases unresponsive to other therapies 1
• Erythromycin is an alternative prokinetic agent 1
  • Only effective for short-term use due to tachyphylaxis (diminishing response) 1
• Domperidone (D2 receptor antagonist) is available outside the US 1
  • Has both prokinetic and antiemetic properties 4

Management of Refractory Gastroparesis

Medication Strategies

• Switching between different prokinetic and antiemetic agents 1
• Combining prokinetic agents when monotherapy fails 1, 4
• Withdrawing medications that may worsen gastroparesis (opioids, anticholinergics, tricyclic antidepressants, GLP-1 receptor agonists, pramlintide) 1

Interventional Approaches

• Gastric electrical stimulation (GES) for severe, refractory cases 1
  • FDA-approved under humanitarian device exemption 2
  • May improve symptoms with modest effects on gastric emptying 1
  • Most beneficial for patients with diabetic gastroparesis 5
• Pyloric interventions for refractory cases:
  • Endoscopic injection of botulinum toxin into the pyloric sphincter 1
    • May provide modest temporary symptom improvement 1
    • Limited evidence from controlled trials 2
  • Endoscopic pyloromyotomy in select cases 6

Nutritional Support for Severe Cases

• Jejunostomy feeding tubes for patients unable to maintain adequate nutrition orally 1
  • Provides route for enteral nutrition, hydration, and medications 1
• Decompressing gastrostomy tubes may be needed in some cases 1
• Parenteral nutrition is rarely required 2

Special Considerations for Diabetic Gastroparesis

• Careful regulation of glycemic control is essential as hyperglycemia can worsen gastric emptying 5
• Metoclopramide may be administered intravenously initially for severe symptoms before transitioning to oral therapy 3

Treatment Algorithm

1. Start with dietary modifications and optimize glycemic control (if diabetic)
2. Add antiemetic therapy for nausea/vomiting symptoms
3. Add prokinetic therapy (metoclopramide or erythromycin) if symptoms persist
4. For refractory cases, consider combination therapy or switching medications
5. For severe refractory cases, consider gastric electrical stimulation or feeding tubes
6. Surgical interventions should be considered only as a last resort in carefully selected patients 2

Monitoring and Follow-up

• Monitor for medication side effects, especially with metoclopramide (extrapyramidal symptoms) 1, 3
• Assess nutritional status regularly and adjust treatment plan accordingly 2
• Evaluate treatment response based on symptom improvement rather than normalization of gastric emptying 6