What is the treatment for gastroparesis?

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

Initial Management Approach

Dietary Modifications (First-Line)

• Eat frequent smaller-sized meals and replace solid food with liquids such as soups 1, 3
• Foods should be low in fat and fiber content 4, 1, 3
• Small particle size diet may improve key symptoms 4, 1, 3
• Liquid supplementation may be necessary for adequate nutrition 3

Medication Withdrawal

• Immediately discontinue medications that worsen gastrointestinal motility, including opioids, anticholinergics, tricyclic antidepressants, GLP-1 receptor agonists, and pramlintide 4, 1
• The risk of removing GLP-1 RAs should be balanced against their potential benefits in diabetic patients 4

Pharmacologic Therapy

Metoclopramide (First-Line Prokinetic):

• Dosing: 10 mg three times daily before meals for at least 4 weeks 1, 3, 2
• Can be administered orally or intravenously 3, 2
• FDA-approved specifically for diabetic gastroparesis 1, 2
• Critical limitation: Use should be limited to 12 weeks maximum due to black box warning for tardive dyskinesia and extrapyramidal symptoms 4, 1, 3
• Should be reserved for severe cases unresponsive to other therapies 4
• In renal impairment (creatinine clearance <40 mL/min), initiate at half the recommended dose 2

Antiemetic Agents:

• Administered for nausea and vomiting control 1
• Principal classes include antidopaminergics (prochlorperazine, trimethobenzamide, promethazine), antihistamines, anticholinergics, and 5-HT3 receptor antagonists 1
• 5-HT3 antagonists are best used on an as-needed basis 1

Special Considerations for Diabetic Gastroparesis

• Careful regulation of glycemic control is essential, as hyperglycemia worsens gastric emptying 3

Management of Refractory Gastroparesis

Definition: Persistent symptoms despite dietary adjustment and metoclopramide therapy 1

Symptom-Based Treatment Algorithm

For Nausea/Vomiting Predominant Symptoms:

• Mild severity: Anti-emetic agents 1
• Moderate severity: Combination of anti-emetic and prokinetic agents, cognitive behavioral therapy/hypnotherapy, liquid diet 1
• Severe symptoms: Consider enteral feeding via jejunostomy tube or gastric electrical stimulation 1, 3

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

• Erythromycin: Can be administered orally or intravenously, but only effective for short-term use due to tachyphylaxis 4, 1, 3
• Domperidone: A dopamine D2 receptor antagonist (not FDA-approved in the United States but available in Canada, Mexico, and Europe) 1

Interventional Therapies for Severe Refractory Cases

Enteral Nutrition:

• Jejunostomy tube feeding should be considered for patients with persistent vomiting or weight loss 3
• Gastric rest with nasoduodenal tube feeding for three months can achieve symptom response in 47% of patients with significant weight gain 5

Gastric Electrical Stimulation:

• FDA-approved for severe symptoms refractory to other treatments 4, 1
• Efficacy is variable and use is limited to individuals with severe refractory symptoms 4

Endoscopic Therapies:

• Intrapyloric botulinum toxin injection is NOT recommended based on placebo-controlled studies showing no benefit 1
• Gastric per-oral endoscopic myotomy (G-POEM) should only be performed at tertiary care centers by experts in treating refractory gastroparesis 1, 3

Common Pitfalls to Avoid

• Do not continue metoclopramide beyond 12 weeks due to serious adverse effect risks 4, 1, 3
• Do not pursue intrapyloric botulinum toxin injection as evidence shows no benefit over placebo 1
• Do not overlook medication withdrawal as a critical first step—many commonly prescribed medications worsen gastroparesis 4, 1
• In diabetic patients, do not neglect glycemic control optimization as hyperglycemia directly impairs gastric emptying 3