What is the management of diabetic (DM) gastroparesis?

Management of Diabetic Gastroparesis

Initial Management: Dietary Modifications

Begin with low-fat, low-fiber meals consisting of 5-6 small, frequent feedings per day, as this is the cornerstone of gastroparesis management. 1

• Replace solid foods with liquids (soups, nutritional supplements) in patients with severe symptoms to facilitate gastric emptying 1
• Focus on foods with small particle size and complex carbohydrates to improve key symptoms 1
• Use energy-dense liquids in small volumes to maintain adequate caloric intake 1
• Strictly avoid high-fat and high-fiber foods that delay gastric emptying 1, 2
• Limit fat intake to less than 30% of total calories 1

Optimize Glycemic Control

• Aggressively optimize blood glucose control, as hyperglycemia directly worsens gastric emptying and perpetuates symptoms 3, 4
• Consider insulin pump therapy in patients with type 1 diabetes for better glycemic stability 5
• Adjust insulin timing and dosing to match delayed food absorption, as insulin may act before food leaves the stomach, leading to hypoglycemia 6

Medication Review and Withdrawal

Immediately discontinue medications that worsen gastroparesis, including opioids, anticholinergics, tricyclic antidepressants, and GLP-1 receptor agonists. 7, 3

• Balance the risk of removing GLP-1 receptor agonists against their glycemic benefits, though withdrawal should be strongly considered 7
• Recognize that medication-induced gastroparesis is a common and reversible cause 1

First-Line Pharmacologic Therapy: Metoclopramide

Metoclopramide 10 mg three times daily before meals is the only FDA-approved medication for gastroparesis and should be the first pharmacologic choice. 1, 6

• Initiate treatment for at least 4 weeks to determine efficacy in diabetic gastroparesis 1
• Strictly limit use to ≤12 weeks due to FDA black box warning for tardive dyskinesia risk 1, 7
• Start with intravenous or intramuscular administration (10 mg slowly over 1-2 minutes) if severe symptoms are present, then transition to oral therapy 6
• In patients with creatinine clearance <40 mL/min, initiate at approximately half the recommended dose 6
• Be aware that extrapyramidal symptoms (acute dystonic reactions, drug-induced parkinsonism, akathisia) are more common in pediatric and geriatric populations 6
• Treat acute dystonic reactions with 50 mg diphenhydramine intramuscularly 6

Second-Line Pharmacologic Options

• Erythromycin (oral or intravenous) can be used for short-term management when metoclopramide fails or is not tolerated, but tachyphylaxis develops rapidly, limiting its effectiveness 1, 3
• Phenothiazines (prochlorperazine, trimethobenzamide, promethazine) for nausea and vomiting control 1
• Serotonin (5-HT3) receptor antagonists (ondansetron) for refractory nausea 1
• Domperidone (available in Canada, Mexico, and Europe but not FDA-approved in the US) as an alternative prokinetic 1

Management of Refractory Gastroparesis

For patients unable to maintain adequate oral intake despite dietary modifications and pharmacologic therapy, consider jejunostomy tube feeding to bypass the stomach. 1, 2

• Place a decompressing gastrostomy in cases requiring gastric decompression 1
• Botulinum toxin injection into the pyloric sphincter may provide modest temporary symptom improvement in highly selected patients 1
• Gastric per-oral endoscopic myotomy (G-POEM) can be considered in severe, refractory cases 1
• Total parenteral nutrition is rarely necessary and should be reserved for extreme cases 2

Nutritional Monitoring

• Target 25-30 kcal/kg/day (1250-1500 kcal daily for a 50 kg patient) to promote weight restoration 1
• Aim for protein intake of 1.2-1.5 g/kg/day (60-75g daily for a 50 kg patient) to address malnutrition 1
• Monitor weekly weights to assess nutritional adequacy 1
• Screen for micronutrient deficiencies (vitamin B12, vitamin D, iron, calcium) and supplement as needed 1
• Consider oral nutritional supplements between meals to increase caloric and protein intake 1

Critical Pitfalls to Avoid

• Never continue metoclopramide beyond 12 weeks without careful reassessment and documentation of ongoing benefit versus tardive dyskinesia risk 1, 7
• Do not overlook medication-induced gastroparesis from opioids or GLP-1 agonists 1, 7
• Avoid high-fat, high-fiber foods that will exacerbate delayed gastric emptying 1
• Do not lie down for at least 2 hours after eating to reduce symptom severity 1
• Be cautious with metoclopramide in patients with hypertension, as it releases catecholamines 6
• Monitor for fluid retention and volume overload in patients with cirrhosis or congestive heart failure receiving metoclopramide 6