Treatment Options for Gastroparesis
Gastroparesis treatment begins with dietary modifications and metoclopramide (the only FDA-approved medication), followed by a stepwise escalation to alternative prokinetics, antiemetics, and ultimately interventional therapies for refractory cases. 1, 2
Initial Dietary Management
All patients should start with dietary modifications as first-line therapy before or concurrent with pharmacologic treatment. 1, 2
- Implement 5-6 small, frequent meals daily instead of 3 large meals to minimize gastric distension 1
- Focus on low-fat, low-fiber foods with small particle size, as fat and fiber delay gastric emptying 1, 2
- Use complex carbohydrates and energy-dense liquids in small volumes 1
- For severe symptoms, replace solid food entirely with liquids such as soups 1, 2
- Avoid lying down for at least 2 hours after eating 1
Medication Withdrawal
Before initiating prokinetic therapy, withdraw all medications that worsen gastroparesis. 2, 3
- Discontinue opioids, anticholinergics, tricyclic antidepressants, GLP-1 receptor agonists, and pramlintide 2, 3
- In diabetic patients, optimize glycemic control as hyperglycemia directly impairs gastric emptying 3
First-Line Pharmacologic Therapy
Metoclopramide (Only FDA-Approved Agent)
Metoclopramide 10 mg three times daily before meals is the first-line prokinetic agent. 1, 2, 4
- Treat for at least 4 weeks to determine efficacy in diabetic gastroparesis 1, 2
- Limit use to 12 weeks maximum due to FDA black box warning for tardive dyskinesia and extrapyramidal symptoms 1, 2, 3
- For severe symptoms, IV metoclopramide (10 mg slowly over 1-2 minutes) may be used initially, with transition to oral therapy once symptoms improve 4
- In patients with creatinine clearance below 40 mL/min, start at half the recommended dose 4
Common pitfall: Continuing metoclopramide beyond 12 weeks without careful reassessment significantly increases tardive dyskinesia risk. 1
Antiemetic Agents
Antiemetics should be used concurrently to control nausea and vomiting. 2
- Phenothiazines (prochlorperazine, trimethobenzamide, promethazine) are first-line antiemetics 1, 2
- Serotonin (5-HT3) receptor antagonists (ondansetron) for refractory nausea, best used on an as-needed basis 1, 2
- Antihistamines and anticholinergics are alternative options 2
Second-Line Pharmacologic Therapy
When Metoclopramide Fails or Is Contraindicated
Erythromycin is reserved for patients who fail or cannot tolerate metoclopramide, particularly useful for short-term or acute settings. 3
- Can be administered orally or intravenously 1, 2
- Major limitation: rapid development of tachyphylaxis limits effectiveness to short-term use only 1, 3
- Particularly useful in hospitalized patients or acute exacerbations 3
Domperidone (dopamine D2 receptor antagonist) is available in Canada, Mexico, and Europe but not FDA-approved in the United States 1, 2
Management Algorithm for Refractory Gastroparesis
Refractory gastroparesis is defined as persistent symptoms despite dietary adjustment and metoclopramide therapy. 2
Symptom-Based Treatment Approach
For nausea/vomiting-predominant symptoms: 2
- Mild: Antiemetic agents alone
- Moderate: Combination of antiemetic and prokinetic agents, consider cognitive behavioral therapy/hypnotherapy, advance to liquid diet
- Severe: Enteral feeding via jejunostomy tube or gastric electrical stimulation
For abdominal pain/discomfort-predominant symptoms: 2
- Treat similar to functional dyspepsia
- Consider augmentation therapy and address comorbid affective disorders (depression, anxiety)
Interventional Therapies for Severe Refractory Cases
Jejunostomy tube feeding should be considered for patients unable to maintain adequate oral intake despite maximal medical therapy. 1, 2
- Bypasses the stomach entirely, allowing nutritional support 1
- Decompressing gastrostomy may be necessary in some cases 1
Gastric electrical stimulation (GES) may relieve symptoms including weekly vomiting frequency and need for nutritional supplementation 2, 5
- Approved on humanitarian device exemption by FDA 5
- Based primarily on open-label studies showing benefit, especially in diabetic gastroparesis 5, 6
Gastric per-oral endoscopic myotomy (G-POEM) should only be performed at tertiary care centers by experts in treating refractory gastroparesis 1, 2
Therapies NOT Recommended
Intrapyloric botulinum toxin injection is NOT recommended based on placebo-controlled studies showing no benefit 2
- Despite initial enthusiasm, randomized controlled trials failed to demonstrate efficacy 2
Partial gastrectomy and pyloroplasty should be used rarely, only in carefully selected patients with end-stage disease when all other therapy has failed. 5, 7
Nutritional Monitoring for Severe Cases
Weekly weight measurements and assessment for micronutrient deficiencies are essential. 1
- Monitor for vitamin B12, vitamin D, iron, and calcium deficiencies 1
- Target protein intake of 1.2-1.5 g/kg/day (60-75g daily for a 50kg patient) 1
- Aim for 25-30 kcal/kg/day (1250-1500 kcal daily) to promote weight restoration 1
- Limit fat intake to less than 30% of total calories 1
- Consider oral nutritional supplements between meals 1
Practical Treatment Algorithm
- Confirm diagnosis with gastric emptying scintigraphy (4-hour solid meal study) 2
- Implement dietary modifications (low-fat, low-fiber, small frequent meals) and withdraw offending medications 1, 2, 3
- Start metoclopramide 10 mg three times daily (if no contraindications) plus appropriate antiemetics 1, 2
- Optimize glycemic control in diabetic patients 3
- If symptoms persist after 4 weeks, consider alternative or combination prokinetic agents (erythromycin) and intensified antiemetic therapy 2, 3
- For truly refractory cases, refer to tertiary center for gastric electrical stimulation, enteral feeding via jejunostomy, or consideration of G-POEM 2