What are the treatment options for gastroparesis?

Treatment of Gastroparesis

The American Gastroenterological Association recommends treating gastroparesis with dietary modifications (frequent small meals, low-fat/low-fiber foods, liquid supplementation) combined with metoclopramide 10 mg three times daily before meals as first-line therapy, which is the only FDA-approved medication for this condition. 1, 2, 3

Initial Management Strategy

Dietary Modifications (First-Line)

• Eat frequent smaller-sized meals and replace solid food with liquids such as soups. 1, 2
• Foods must be low in fat and fiber content. 1, 2
• A small particle size diet improves key symptoms according to the American Diabetes Association. 1, 2
• Liquid supplementation may be necessary for adequate nutrition. 2

Medication Review

• Withdraw medications that worsen gastroparesis immediately: opioids, anticholinergics, tricyclic antidepressants, GLP-1 receptor agonists, and pramlintide. 1, 2

Glycemic Control (Diabetic Patients)

• Careful regulation of glycemic control is essential as hyperglycemia worsens gastric emptying. 2
• Insulin dosage or timing may require adjustment since metoclopramide influences food delivery to intestines and absorption rate. 3

Pharmacologic Therapy

Metoclopramide (First-Line Prokinetic)

• Metoclopramide is FDA-approved specifically for diabetic gastroparesis and is the only approved medication for this condition. 1, 3
• Standard dosing: 10 mg orally three times daily before meals for at least 4 weeks. 1, 3
• For severe symptoms, begin with IV/IM administration (10 mg slowly over 1-2 minutes), then transition to oral when symptoms improve. 3
• FDA recommends limiting treatment to 12 weeks maximum due to risk of tardive dyskinesia and extrapyramidal symptoms. 1, 3
• The black box warning for tardive dyskinesia exists, though actual risk may be lower than previously estimated. 1
• In renal impairment (creatinine clearance <40 mL/min), initiate at half the recommended dose. 3

Antiemetic Agents

• Antiemetics are administered for nausea and vomiting control. 1
• Principal classes include:
  • Antidopaminergics (prochlorperazine, trimethobenzamide, promethazine) 1
  • Antihistamines 1
  • Anticholinergics 1
  • Serotonin (5-HT3) receptor antagonists - best used on an as-needed basis 1

Alternative Prokinetic Agents

• Erythromycin can be administered orally or intravenously but is effective only for short-term use due to tachyphylaxis. 1, 2
• Domperidone is a dopamine (D2) receptor antagonist available in Canada, Mexico, and Europe but not FDA-approved in the United States. 1

Management Algorithm for Refractory Gastroparesis

Medically refractory gastroparesis is defined as persistent symptoms despite dietary adjustment and metoclopramide therapy. 1

Symptom-Based Treatment Approach

For Nausea/Vomiting Predominant Symptoms:

• Mild symptoms: Anti-emetic agents 1
• Moderate symptoms: Combination of anti-emetic and prokinetic agents, cognitive behavioral therapy/hypnotherapy, liquid diet 1
• Severe symptoms: Consider enteral feeding (J tube) or gastric electrical stimulation 1

For Abdominal Pain/Discomfort Predominant Symptoms:

• Treat similar to functional dyspepsia 1
• Consider augmentation therapy for moderate symptoms 1
• Address comorbid affective disorders 1

After 4 Weeks of Optimal Therapy Without Improvement:

• Alternative or combination prokinetic agents 1
• Intensified antiemetic therapy 1

Advanced Interventions for Truly Refractory Cases

Enteral Nutrition

• Enteral nutrition via jejunostomy tube should be considered for patients with persistent vomiting or weight loss. 2
• Parenteral nutrition is rarely required and only when hydration and nutritional state cannot be maintained. 4

Gastric Electrical Stimulation (GES)

• GES may relieve symptoms including weekly vomiting frequency and need for nutritional supplementation based on open-label studies. 1, 4
• Should only be performed at tertiary care centers. 1

Endoscopic Interventions

• Gastric per-oral endoscopic myotomy (G-POEM) should only be performed at tertiary care centers by experts in treating refractory gastroparesis. 1, 2
• Intrapyloric botulinum toxin injection is NOT recommended based on placebo-controlled studies showing no benefit. 1

Surgical Options

• Venting gastrostomy or feeding jejunostomy are second-line approaches. 4
• Partial gastrectomy and pyloroplasty should be used rarely, only in carefully selected patients. 4

Critical Pitfalls to Avoid

• Do not use metoclopramide beyond 12 weeks due to serious adverse effects. 1
• Avoid rapid IV administration of metoclopramide (must be given over 1-2 minutes for 10 mg doses) as it causes transient intense anxiety and restlessness. 3
• Exercise caution in hypertensive patients as metoclopramide releases catecholamines. 3
• Monitor for fluid retention in patients with cirrhosis or congestive heart failure due to transient increase in plasma aldosterone. 3
• Dystonic reactions are more common in pediatric populations; if they occur, inject 50 mg diphenhydramine intramuscularly. 3
• Geriatric patients should receive the lowest effective dose due to increased risk of parkinsonian-like side effects. 3