What are the treatment options for gastroparesis?

Treatment Options for Gastroparesis

Begin with dietary modifications (low-fat, low-fiber, small frequent meals with liquid calories) and metoclopramide 10 mg three times daily before meals, which is the only FDA-approved medication for gastroparesis, though use should be limited to 12 weeks due to risk of tardive dyskinesia. 1, 2, 3

Initial Dietary Management

• Implement 5-6 small, frequent meals daily instead of three large meals to minimize gastric distension 1, 2
• Focus on low-fat foods (limit fat to <30% of total calories) as fat delays gastric emptying 1, 2
• Choose low-fiber options since fiber slows gastric transit 1, 2
• Emphasize foods with small particle size to improve symptom control 1, 2
• Replace solid foods with liquids (soups, nutritional supplements) in patients with severe symptoms 1, 2
• Use complex carbohydrates and energy-dense liquids in small volumes 2

Medication Review and Optimization

Before starting new medications, withdraw drugs that worsen gastroparesis: 1, 4

• Opioids 1, 4
• Anticholinergics 1, 4
• Tricyclic antidepressants 1, 4
• GLP-1 receptor agonists (though balance this against their metabolic benefits in diabetic patients) 1, 4
• Pramlintide 1

First-Line Pharmacologic Therapy

Metoclopramide is the cornerstone of pharmacologic treatment: 1, 2, 3

• Dose: 10 mg three times daily before meals 2, 3
• Continue for at least 4 weeks to assess efficacy 2, 4
• Critical limitation: FDA black box warning restricts use beyond 12 weeks due to risk of extrapyramidal symptoms and tardive dyskinesia 1, 2, 4
• Reserve for severe cases unresponsive to dietary measures 1
• For severe acute symptoms, may give 10 mg IV slowly over 1-2 minutes 3

Antiemetic agents for nausea and vomiting control: 2, 4

• Phenothiazines (prochlorperazine, trimethobenzamide, promethazine) 2, 4
• Serotonin 5-HT3 receptor antagonists (ondansetron) for refractory nausea, best used as-needed 2, 4
• Antihistamines 4

Second-Line Pharmacologic Options

When metoclopramide fails or cannot be used: 2, 4

• Erythromycin: Effective short-term only due to tachyphylaxis; can be given orally or IV 1, 2, 4
• Domperidone: Available outside the U.S. (Canada, Mexico, Europe) as a dopamine D2 antagonist with fewer CNS side effects than metoclopramide 1, 2, 4

Management of Refractory Gastroparesis

For patients failing dietary modifications and optimal medical therapy after 4 weeks: 4

Nutritional Support Interventions

• Jejunostomy tube feeding: Consider when patients cannot maintain adequate oral intake despite medical therapy 1, 2, 4
• Decompressing gastrostomy: May be necessary in some refractory cases 2
• Parenteral nutrition is rarely required 5

Procedural Interventions

• Gastric electrical stimulation (GES): FDA-approved on humanitarian device exemption for severe refractory symptoms, though efficacy data are limited and variable 1, 2, 4, 5
• Gastric per-oral endoscopic myotomy (G-POEM): Should only be performed at tertiary care centers by experts in refractory gastroparesis 2, 4
• Intrapyloric botulinum toxin injection: NOT recommended based on placebo-controlled trials showing no benefit 4, 5

Surgical Options (Last Resort)

• Partial gastrectomy and pyloroplasty should be used rarely, only in carefully selected patients at specialized centers 5

Treatment Algorithm Based on Symptom Severity

Mild symptoms: 4

• Dietary modifications + antiemetic agents as needed

Moderate symptoms: 4

• Dietary modifications + metoclopramide + antiemetics
• Consider liquid diet
• Cognitive behavioral therapy/hypnotherapy may help

Severe symptoms: 4

• All of the above plus:
• Consider jejunostomy tube feeding
• Evaluate for gastric electrical stimulation at tertiary center
• G-POEM at expert centers only

Special Considerations for Diabetic Gastroparesis

• Optimize glycemic control as hyperglycemia itself delays gastric emptying 4, 5
• Initial treatment with metoclopramide should be for at least 4 weeks to determine efficacy 2

Critical Pitfalls to Avoid

• Do not continue metoclopramide beyond 12 weeks without careful reassessment due to cumulative risk of tardive dyskinesia 1, 2, 4
• Do not overlook medication-induced gastroparesis from opioids or GLP-1 agonists before adding more medications 1, 4
• Do not use intrapyloric botulinum toxin as it has proven ineffective in controlled trials 4, 5
• Do not perform G-POEM outside tertiary care centers with expertise in refractory gastroparesis 2, 4

Monitoring and Follow-up

• Assess treatment effectiveness after 4 weeks of therapy 2, 4
• Monitor for metoclopramide side effects (extrapyramidal symptoms, tardive dyskinesia) 1, 2
• Track nutritional status with weekly weights in severe cases 2
• Monitor for micronutrient deficiencies (vitamin B12, vitamin D, iron, calcium) 2