What are the treatment options for gastroparesis?

Treatment of Gastroparesis

Immediate First Steps: Dietary Modifications and Medication Review

Begin treatment with low-fat, low-fiber meals consisting of 5-6 small, frequent feedings per day, as this is the cornerstone of gastroparesis management. 1, 2

• Replace solid foods with liquids (soups, energy-dense liquid supplements) in patients with severe symptoms to facilitate gastric emptying 1, 2
• Focus on foods with small particle size and complex carbohydrates to improve key symptoms 1, 2
• Limit fat intake to less than 30% of total calories to promote gastric emptying 1
• Avoid lying down for at least 2 hours after eating to reduce symptom severity 1, 2

Immediately discontinue medications that worsen gastroparesis, including opioids, anticholinergics, tricyclic antidepressants, and GLP-1 receptor agonists, as medication-induced gastroparesis is a common and reversible cause. 1, 2, 3

• For diabetic patients, aggressively optimize blood glucose control, as hyperglycemia directly worsens gastric emptying and perpetuates symptoms 2, 3

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, 2, 3, 4

• Initiate treatment for at least 4 weeks to determine efficacy in diabetic gastroparesis 1, 2
• Strictly limit use to ≤12 weeks due to FDA black box warning for tardive dyskinesia risk 1, 2, 3
• Never continue metoclopramide beyond 12 weeks without careful reassessment and documentation of ongoing benefit versus tardive dyskinesia risk 1, 2
• If acute dystonic reactions occur, inject 50 mg diphenhydramine intramuscularly 4

Second-Line Pharmacologic Options

Reserve erythromycin for patients who fail or cannot tolerate metoclopramide, particularly in acute settings or when intravenous therapy is needed. 2, 3

• Erythromycin can be administered orally or intravenously for short-term use, but the major limitation is rapid development of tachyphylaxis, making it effective only for short-term management 1, 2, 3
• Phenothiazines (prochlorperazine, trimethobenzamide, promethazine) can be used for nausea and vomiting control 1, 2
• Serotonin (5-HT3) receptor antagonists (ondansetron) can be used for refractory nausea 1, 2
• Domperidone (not FDA-approved in the US) can be used as an alternative prokinetic in Canada, Mexico, and Europe 1, 2

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, 2
• Botulinum toxin injection into the pyloric sphincter may provide modest temporary symptom improvement in highly selected patients with refractory gastroparesis 1, 2
• Gastric per-oral endoscopic myotomy (G-POEM) may be considered in severe, refractory cases 1, 2

Nutritional Monitoring and Support

Target 25-30 kcal/kg/day to promote weight restoration and aim for protein intake of 1.2-1.5 g/kg/day to address malnutrition. 1, 2

• Monitor weekly weights to assess nutritional adequacy 1, 2
• 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, 2

Critical Pitfalls to Avoid

• Do not overlook medication-induced gastroparesis from opioids or GLP-1 agonists, as this is a common and reversible cause 1, 2, 3
• Avoid high-fat, high-fiber foods that will exacerbate delayed gastric emptying 1, 2
• In patients with creatinine clearance below 40 mL/min, initiate metoclopramide at approximately one-half the recommended dosage 4