What are the treatment options for gastroparesis?

Treatment Options for Gastroparesis

Dietary Management as Foundation

All patients with gastroparesis should begin with dietary modifications consisting of 5-6 small, low-fat, low-fiber meals daily, with severe cases requiring liquid-based nutrition such as soups. 1

• Implement foods with small particle size to improve key symptoms 1, 2
• Use complex carbohydrates and energy-dense liquids in small volumes 1
• Avoid high-fat foods (limit to <30% of total calories) and high-fiber foods that delay gastric emptying 1
• Replace solid food with liquids when symptoms are severe 1, 2
• Avoid lying down for at least 2 hours after eating 1

First-Line Pharmacologic Treatment

Metoclopramide 10 mg three times daily before meals is the only FDA-approved medication for gastroparesis and should be the initial pharmacologic choice. 1, 2, 3

Metoclopramide Dosing and Duration

• Administer 10 mg orally three times daily before meals for at least 4 weeks to determine efficacy 1, 3
• Treatment must be limited to 12 weeks maximum due to FDA black box warning for tardive dyskinesia 1, 2
• For severe symptoms, IV administration at 10 mg slowly over 1-2 minutes may be used, with up to 10 days of IV therapy before transitioning to oral 3
• In patients with creatinine clearance below 40 mL/min, initiate at approximately half the recommended dose 3

Critical Medication Withdrawal

• Immediately discontinue medications that worsen gastroparesis: opioids, GLP-1 receptor agonists, anticholinergics, tricyclic antidepressants, and pramlintide 1, 2, 4

Antiemetic Therapy

Antiemetic agents should be used concurrently with prokinetics to control nausea and vomiting. 1, 2

• Phenothiazines (prochlorperazine, trimethobenzamide, promethazine) for nausea and vomiting 1
• Serotonin (5-HT3) receptor antagonists (ondansetron) for refractory nausea, best used on an as-needed basis 1, 2
• Antihistamines and anticholinergics as additional options 2

Second-Line Prokinetic Agents

Erythromycin

• Reserve erythromycin for patients who fail or cannot tolerate metoclopramide, particularly useful for short-term or acute settings 4
• Can be administered orally or intravenously 1, 2
• Recommended dosing of 900 mg/day in patients with severe gastroparesis 4
• Major limitation is rapid development of tachyphylaxis, making it effective only for short-term use 4

Domperidone

• Available in Canada, Mexico, and Europe but not FDA-approved in the United States 1, 2
• Acts as a dopamine (D2) receptor antagonist with prokinetic and antiemetic properties 2

Management Algorithm for Refractory Gastroparesis

Refractory gastroparesis is defined as persistent symptoms despite dietary adjustment and metoclopramide therapy. 2

For Nausea/Vomiting-Predominant Symptoms:

• Mild: Antiemetic agents 2
• Moderate: Combination of antiemetic and prokinetic agents, cognitive behavioral therapy/hypnotherapy, liquid diet 2
• Severe: Consider enteral feeding via jejunostomy tube or gastric electrical stimulation 2

For Abdominal Pain-Predominant Symptoms:

• Treat similar to functional dyspepsia 2
• Consider augmentation therapy for moderate symptoms 2
• Address comorbid affective disorders 2

Nutritional Support for Severe Cases

Jejunostomy tube feeding should be initiated if oral intake remains below 50-60% of energy requirements for more than 10 days despite dietary modifications and medical therapy. 1

Jejunostomy Tube Feeding Protocol:

• Jejunostomy is the preferred route because it bypasses the dysfunctional stomach entirely 1
• Use nasojejunal tube for anticipated duration <4 weeks or trial period 1
• Use percutaneous endoscopic jejunostomy (PEJ) for anticipated duration >4 weeks 1
• Never use gastrostomy (PEG) tubes in gastroparesis as they deliver nutrition into the dysfunctional stomach and will not bypass the emptying problem 1
• Start continuous feeding at 10-20 mL/hour and gradually advance over 5-7 days to reach target intake 1
• Target 25-30 kcal/kg/day and protein intake of 1.2-1.5 g/kg/day 1

Decompressing Gastrostomy:

• May be necessary in some cases of refractory gastroparesis for symptom relief 1

Advanced Interventions for Treatment-Resistant Cases

Gastric Electrical Stimulation (GES):

• Consider for patients with refractory symptoms who fail medical management 2, 5
• Approved on humanitarian device exemption by FDA 5
• May relieve symptoms including weekly vomiting frequency and need for nutritional supplementation 5

Gastric Per-Oral Endoscopic Myotomy (G-POEM):

• Should only be performed at tertiary care centers by experts in treating refractory gastroparesis 1, 2
• May be considered in severe cases of refractory gastroparesis 1

Botulinum Toxin Injection:

• Intrapyloric botulinum toxin injection is NOT recommended based on placebo-controlled studies showing no benefit 2
• May provide only modest temporary symptom improvement in highly selected patients 1

Special Considerations for Diabetic Gastroparesis

• Optimize glycemic control as hyperglycemia worsens gastric emptying 4
• Initial metoclopramide treatment should be for at least 4 weeks to determine efficacy 1

Critical Pitfalls to Avoid

• Do not continue metoclopramide beyond 12 weeks without careful reassessment due to risk of tardive dyskinesia 1, 2
• Do not fail to recognize medication-induced gastroparesis from opioids and GLP-1 agonists 1
• Do not delay tube feeding beyond 10 days of inadequate intake in documented gastroparesis, as malnutrition significantly worsens outcomes 1
• Do not use gastrostomy tubes in gastroparesis patients 1

Parenteral Nutrition

• Reserve parenteral nutrition as a last resort only when jejunal feeding fails or is contraindicated 1, 5
• Use only for short-term when hydration and nutritional state cannot be maintained enterally 1
• Be aware of higher complication rates including catheter-related sepsis 1