What are the treatment options for gastroparesis?

Treatment Options for Gastroparesis

The treatment of gastroparesis should focus on dietary modifications as first-line therapy, with pharmacologic interventions reserved for more severe cases that don't respond to conservative measures. 1, 2

Dietary and Nutritional Management

• A low-fiber, low-fat eating plan provided in small, frequent meals with a greater proportion of liquid calories is the cornerstone of initial treatment for gastroparesis 1, 2
• Foods with small particle size improve key symptoms and should be recommended to all patients with gastroparesis 1, 2
• Liquid nutritional supplements may be necessary to maintain adequate nutrition in patients with significant symptoms 2
• For severe cases with persistent vomiting or weight loss, enteral nutrition via jejunostomy tube should be considered 2

Medication Management

First-Line Pharmacologic Therapy

• Withdrawing medications that adversely affect gastrointestinal motility is essential, including:

  • Opioids
  • Anticholinergics
  • Tricyclic antidepressants
  • GLP-1 receptor agonists
  • Pramlintide 1, 2

• Metoclopramide is the only FDA-approved medication for gastroparesis treatment:

  • Standard dosing is 10 mg three times daily before meals 3
  • Should be used cautiously due to risk of serious adverse effects (extrapyramidal symptoms, tardive dyskinesia) 1
  • FDA recommends limiting use to 12 weeks due to safety concerns 1, 3
  • Should be reserved for severe cases unresponsive to other therapies 1

Alternative Pharmacologic Options

• Erythromycin can be effective but only for short-term use due to tachyphylaxis (diminishing response over time) 1, 2
• Domperidone is available outside the U.S. and may be considered for patients who cannot tolerate metoclopramide 1, 4

Management of Refractory Gastroparesis

• For diabetic patients, careful regulation of glycemic control is essential as hyperglycemia can worsen gastric emptying 2
• Gastric electrical stimulation using a surgically implantable device has FDA approval for treatment of refractory gastroparesis, though the most recent evidence suggests limited efficacy in diabetic gastroparesis 1
• For severe, refractory cases, surgical options may include:
  • Venting gastrostomy to relieve nausea and vomiting 4
  • Feeding jejunostomy to bypass the stomach for nutrition 4
  • Partial gastrectomy or pyloroplasty should be used rarely and only in carefully selected patients 4

Treatment Algorithm

1. Start with dietary modifications (small, frequent, low-fat, low-fiber meals with increased liquid content)
2. Discontinue medications that delay gastric emptying
3. For persistent symptoms, add metoclopramide (limited to 12 weeks)
4. For patients who cannot tolerate metoclopramide, consider erythromycin (short-term) or domperidone (if available)
5. For refractory cases, consider gastric electrical stimulation or enteral feeding via jejunostomy tube
6. Reserve surgical interventions for the most severe, treatment-resistant cases

Important Considerations and Pitfalls

• Metoclopramide should be used with extreme caution in elderly patients due to increased risk of extrapyramidal side effects 1, 3
• Patients should be monitored closely for development of tardive dyskinesia, which can be irreversible 3
• In diabetic patients, poor glycemic control can worsen gastroparesis symptoms, creating a vicious cycle 2
• Combination therapy with both prokinetic and antiemetic agents may be necessary for symptom control in refractory cases 5
• The evidence base for many gastroparesis treatments is limited, with few large randomized controlled trials 4