Treatment for Gastroparesis
Begin treatment with dietary modifications (small, frequent, low-fat, low-fiber meals with liquid supplementation) combined with metoclopramide 10 mg three times daily before meals, which is the only FDA-approved medication for gastroparesis. 1, 2, 3
Initial Management Strategy
Step 1: Withdraw Offending Medications
- Discontinue medications that worsen gastric emptying: opioids, anticholinergics, tricyclic antidepressants, GLP-1 receptor agonists, and pramlintide 1, 2
- For diabetic patients, optimize glycemic control as hyperglycemia directly impairs gastric emptying 2, 4
Step 2: 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
- Small particle size diet improves key symptoms 1, 2
- Liquid supplementation may be necessary for adequate nutrition 2
Step 3: Pharmacologic Therapy
Metoclopramide (First-Line Prokinetic):
- Dose: 10 mg three times daily before meals, administered orally or intravenously 1, 2, 3
- Continue for at least 4 weeks to assess response 1
- Critical caveat: FDA black box warning for tardive dyskinesia—limit use to 12 weeks maximum 1, 2, 4
- For severe symptoms, begin with IV/IM administration, then transition to oral when symptoms improve 3
Antiemetic Agents (Concurrent with Prokinetics):
- Antidopaminergics: prochlorperazine, trimethobenzamide, promethazine 1
- Antihistamines 1
- Anticholinergics 1
- 5-HT3 receptor antagonists (ondansetron)—best used as-needed 1
Management of Refractory Gastroparesis
Definition: Persistent symptoms despite dietary adjustment and metoclopramide therapy for 4 weeks 1
Tailor Treatment by Predominant Symptom Pattern
For Nausea/Vomiting-Predominant Symptoms:
- Mild: Intensified antiemetic agents 1
- Moderate: Combination antiemetic + alternative prokinetic, cognitive behavioral therapy/hypnotherapy, liquid diet 1
- Severe: Enteral feeding via jejunostomy tube or gastric electrical stimulation 1, 2
For Abdominal Pain/Discomfort-Predominant Symptoms:
- Treat similar to functional dyspepsia 1
- Consider augmentation therapy for moderate symptoms 1
- Address comorbid affective disorders 1
Alternative Prokinetic Agents (Second-Line)
Erythromycin:
- Effective for short-term use only due to rapid tachyphylaxis 1, 2, 4
- Can be administered orally or intravenously 1
- Reserve for patients who fail or cannot tolerate metoclopramide, particularly useful in acute settings requiring IV therapy 4
Domperidone:
- Dopamine D2 receptor antagonist 1
- Not FDA-approved in the United States but available in Canada, Mexico, and Europe 1
Interventional Therapies for Truly Refractory Cases
Enteral Nutrition:
- Jejunostomy tube feeding for persistent vomiting or weight loss when oral intake is inadequate 1, 2
- Parenteral nutrition is rarely required 5
Gastric Electrical Stimulation (GES):
- Consider for severe refractory symptoms, especially in diabetic gastroparesis 1
- FDA humanitarian device exemption approval 5
- Refer to tertiary care centers 1
Gastric Per-Oral Endoscopic Myotomy (G-POEM):
- Should only be performed at tertiary care centers by experts 1, 2
- Emerging therapy for highly selected refractory cases 1
Therapies NOT Recommended
Intrapyloric Botulinum Toxin Injection:
- Not recommended—placebo-controlled studies showed no benefit 1
Surgical Options (Last Resort):
- Partial gastrectomy and pyloroplasty should be used rarely, only in carefully selected patients 5
- Venting gastrostomy may be considered as second-line approach 5
Special Considerations for Diabetic Gastroparesis
- Careful regulation of glycemic control is essential as hyperglycemia worsens gastric emptying 2, 4
- Multidisciplinary approach involving gastroenterologists, dietitians, and endocrinologists may be necessary 2