What are the treatment options for gastroparesis?

Treatment Options for Gastroparesis

Dietary Management as Foundation

All patients with gastroparesis should implement low-fat, low-fiber meals with 5-6 smaller, more frequent feedings daily as the cornerstone of management. 1

• Replace solid foods with liquids such as soups in patients with severe symptoms 1
• Focus on foods with small particle size and complex carbohydrates to improve key symptoms 1, 2
• Use energy-dense liquids in small volumes 1
• Strictly avoid high-fat and high-fiber foods that delay gastric emptying 1, 2
• Avoid lying down for at least 2 hours after eating 1

First-Line Pharmacologic Therapy

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

• Treat for at least 4 weeks to determine efficacy in diabetic gastroparesis 1, 2
• Limit use to maximum 12 weeks due to FDA black box warning for tardive dyskinesia risk 1, 2, 4
• If severe symptoms are present, initiate therapy with IV metoclopramide (10 mg slowly over 1-2 minutes) before transitioning to oral 3
• In patients with creatinine clearance below 40 mL/min, start at approximately half the recommended dose 3

Critical Medication Withdrawal

Before initiating prokinetic therapy, withdraw all medications that worsen gastroparesis: 1, 2, 4

• Opioids
• GLP-1 receptor agonists (semaglutide, liraglutide)
• Anticholinergics
• Tricyclic antidepressants
• Pramlintide

Antiemetic Therapy

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

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

Second-Line Prokinetic Options

If metoclopramide fails or causes intolerable side effects after 4 weeks, consider erythromycin for short-term use only. 1, 4

• Erythromycin can be administered orally or intravenously at 900 mg/day 1, 4
• Major limitation is rapid tachyphylaxis, making it effective only for short-term intervention 1, 4
• Particularly useful in acute settings or when IV therapy is needed 4
• Consider azithromycin if erythromycin fails for small bowel dysmotility 4

Domperidone is an alternative dopamine D2 receptor antagonist available in Canada, Mexico, and Europe (not FDA-approved in the US). 1, 2

Management of Refractory Gastroparesis

Symptom-Based Treatment Algorithm

For nausea/vomiting predominant symptoms: 2

• Mild: Antiemetic agents alone 2
• Moderate: Combination antiemetic + prokinetic agents, cognitive behavioral therapy/hypnotherapy, liquid diet 2
• Severe: Jejunostomy tube feeding or gastric electrical stimulation 2

For abdominal pain/discomfort predominant symptoms: 2

• Treat similar to functional dyspepsia 2
• Consider augmentation therapy and 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 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 1
• Parenteral nutrition should be reserved only when jejunal feeding fails or is contraindicated 1, 5

Advanced Interventions

Gastric electrical stimulation (GES) may be considered for truly refractory cases with persistent vomiting despite optimal medical therapy. 1, 2, 5

• Approved on humanitarian device exemption by FDA 5
• May relieve symptoms including weekly vomiting frequency and need for nutritional supplementation 5
• Should only be performed at tertiary care centers 2

Gastric per-oral endoscopic myotomy (G-POEM) should only be performed at tertiary care centers by experts in treating refractory gastroparesis. 1, 2

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 directly worsens gastric emptying. 2, 4

Common Pitfalls to Avoid

• Do not continue metoclopramide beyond 12 weeks without careful reassessment due to tardive dyskinesia risk 1, 2
• Do not use gastrostomy tubes—they will not bypass the gastric emptying problem 1
• Do not delay jejunal tube feeding beyond 10 days of inadequate intake in documented gastroparesis, as malnutrition significantly worsens outcomes 1
• Do not fail to recognize and withdraw medication-induced gastroparesis (opioids, GLP-1 agonists) 1, 2
• Do not use intrapyloric botulinum toxin as routine therapy—randomized trials show no benefit 2

Monitoring Nutritional Status

For patients at risk of malnutrition, monitor: 1

• Weekly weight measurements 1
• Micronutrient deficiencies (vitamin B12, vitamin D, iron, calcium) 1
• Protein intake target of 1.2-1.5 g/kg/day 1
• Caloric intake target of 25-30 kcal/kg/day 1