What are the treatment options for gastroparesis?

Treatment Options for Gastroparesis

The first-line treatment for gastroparesis includes dietary modifications, prokinetic medications (particularly metoclopramide), and antiemetic agents, with treatment escalation based on symptom severity and response to initial therapy. 1, 2

Dietary Management

• Eat frequent smaller-sized meals and replace solid food with liquids (such as soups) to improve symptoms 1, 2
• Foods should be low in fat and fiber content to facilitate gastric emptying 1, 2
• Small particle size diet may improve key symptoms in patients with gastroparesis 1, 3
• Liquid nutritional supplements may be necessary for adequate nutrition in patients with severe symptoms 1

Pharmacologic Therapy

Prokinetic Agents

• Metoclopramide is the only FDA-approved medication for gastroparesis, with standard dosing of 10 mg three times daily before meals 1, 2, 4
• Treatment should be limited to 12 weeks due to risk of serious adverse effects including extrapyramidal symptoms and tardive dyskinesia 3, 1, 4
• For severe symptoms, metoclopramide can be initiated intravenously before transitioning to oral administration 4
• Erythromycin is effective for short-term use but limited by tachyphylaxis (diminishing effect over time) 1, 2

Antiemetic Agents

• Antiemetics are essential for controlling nausea and vomiting symptoms 2
• Principal classes include:
  • Antidopaminergics (prochlorperazine, trimethobenzamide, promethazine) 2
  • Antihistamines 2
  • Anticholinergics 2
  • Serotonin (5-HT3) receptor antagonists (best used on an as-needed basis) 2

Management of Refractory Gastroparesis

Medication Adjustments

• Withdraw medications that may worsen gastroparesis, including opioids, anticholinergics, tricyclic antidepressants, GLP-1 receptor agonists, and pramlintide 3, 1
• For diabetic gastroparesis, careful regulation of glycemic control is essential as hyperglycemia can worsen gastric emptying 1, 5

Treatment Based on Predominant Symptoms

• For nausea/vomiting predominant symptoms:
  • Mild: Anti-emetic agents 2
  • Moderate: Combination of anti-emetic and prokinetic agents, cognitive behavioral therapy/hypnotherapy, liquid diet 2
  • Severe: Consider enteral feeding or gastric electrical stimulation 2, 5
• For abdominal pain/discomfort predominant symptoms:
  • Treat similar to functional dyspepsia 2
  • Consider augmentation therapy for moderate symptoms 2

Advanced Interventions

• Enteral nutrition via jejunostomy tube should be considered for patients with persistent vomiting or weight loss who fail medical therapy 1, 2
• Gastric electrical stimulation may be beneficial for refractory cases, particularly in diabetic gastroparesis 6, 5
• Gastric per-oral endoscopic myotomy (G-POEM) should only be performed at tertiary care centers by experts in treating refractory gastroparesis 3, 2

Treatment Algorithm for Gastroparesis

1. Initial Management:

   • Confirm diagnosis with gastric emptying study 2
   • Implement dietary modifications 1, 2
   • Start metoclopramide (if no contraindications) and appropriate antiemetics 2, 4
   • For diabetic patients, optimize glycemic control 1

2. If symptoms persist after 4 weeks of optimal therapy:

   • Consider alternative or combination prokinetic agents 2
   • Intensify antiemetic therapy 2

3. For truly refractory cases:

   • Consider referral to a tertiary center for:
     • Gastric electrical stimulation 2, 5
     • Enteral feeding via jejunostomy 1, 2
     • Emerging endoscopic therapies 2, 5

Important Considerations and Pitfalls

• Metoclopramide should be used cautiously and for limited duration due to risk of tardive dyskinesia 3, 1, 4
• In patients with renal impairment (creatinine clearance below 40 mL/min), metoclopramide therapy should be initiated at approximately half the recommended dosage 4
• Intrapyloric botulinum toxin injection is not recommended based on placebo-controlled studies showing no benefit 2
• A multidisciplinary approach involving gastroenterologists, dietitians, and surgeons is necessary for patients with severe symptoms 1