What are the treatment options for gastroparesis?

Gastroparesis Treatment

Begin treatment with dietary modifications (low-fat, low-fiber, 5-6 small meals daily), immediately discontinue offending medications (opioids, GLP-1 agonists, anticholinergics), optimize glycemic control in diabetics, and use metoclopramide 10 mg three times daily before meals for 4-12 weeks maximum as first-line pharmacologic therapy when dietary measures fail. 1, 2

Step 1: Dietary Modifications (First-Line for All Patients)

• Implement 5-6 small, frequent meals daily with low-fat (<30% of total calories) and low-fiber content to improve gastric emptying 1, 3, 2
• Replace solid foods with liquids (soups, nutritional supplements) in patients with severe symptoms 1, 3
• Focus on small particle size foods and complex carbohydrates to reduce symptom burden 1, 2
• Use energy-dense liquids in small volumes to maintain adequate caloric intake (target 25-30 kcal/kg/day) 3, 2
• Avoid lying down for at least 2 hours after eating to minimize symptom severity 3

Step 2: Medication Review and Withdrawal (Critical First Step)

• Immediately discontinue medications that worsen gastrointestinal motility, including opioids, anticholinergics, tricyclic antidepressants, GLP-1 receptor agonists, and pramlintide 1, 2
• In diabetic patients, balance the risk of removing GLP-1 receptor agonists against their glycemic benefits, though withdrawal should be strongly considered 1, 2
• This step is commonly overlooked but represents a reversible cause of gastroparesis 1, 2

Step 3: Optimize Glycemic Control (Diabetic Gastroparesis)

• Aggressively optimize blood glucose control, as hyperglycemia directly worsens gastric emptying and perpetuates symptoms 1, 2
• Consider insulin pump therapy in type 1 diabetes patients for better glycemic stability 2

Step 4: First-Line Pharmacologic Therapy

Metoclopramide (Only FDA-Approved Agent)

• Metoclopramide 10 mg three times daily before meals is the only FDA-approved medication for gastroparesis and should be initiated for at least 4 weeks to determine efficacy 1, 3, 4
• Strictly limit use to maximum 12 weeks due to FDA black box warning for tardive dyskinesia and extrapyramidal symptoms 1, 3, 2
• The American Gastroenterological Association recommends reserving metoclopramide for severe cases unresponsive to other therapies 1
• In patients with creatinine clearance below 40 mL/min, initiate therapy at approximately one-half the recommended dosage 4

Antiemetic Agents for Symptom Control

• Administer antidopaminergics, antihistamines, anticholinergics, or 5-HT3 receptor antagonists for nausea and vomiting control 1
• Use 5-HT3 antagonists (ondansetron) on an as-needed basis for refractory nausea 1, 3
• Phenothiazines (prochlorperazine, promethazine) can be used for nausea and vomiting 3, 2

Step 5: Management of Refractory Gastroparesis

Refractory gastroparesis is defined as persistent symptoms despite dietary adjustment and metoclopramide therapy. 1

Symptom-Based Approach for Nausea/Vomiting Predominant Disease

• Mild severity: Treat with anti-emetic agents 1
• Moderate severity: Combine anti-emetic and prokinetic agents with cognitive behavioral therapy/hypnotherapy and liquid diet 1
• Severe symptoms: Consider enteral feeding via jejunostomy tube or gastric electrical stimulation 1

Alternative Prokinetic Agents

• Erythromycin (oral or intravenous) can be used for short-term management only, as tachyphylaxis develops rapidly limiting long-term effectiveness 1, 3, 2
• Domperidone (dopamine D2 receptor antagonist) is not FDA-approved in the United States but available in Canada, Mexico, and Europe 1, 3

Nutritional Support for Inadequate Oral Intake

• Jejunostomy tube feeding should be considered for patients with persistent vomiting or weight loss who cannot maintain adequate oral intake (below 50-60% of energy requirements for more than 10 days) 1, 3
• Jejunostomy is preferred over gastrostomy because it bypasses the dysfunctional stomach entirely 3
• Start continuous feeding at low flow rates (10-20 mL/hour) and gradually advance over 5-7 days to reach target intake 3
• Use nasojejunal tube for anticipated duration <4 weeks; use percutaneous endoscopic jejunostomy (PEJ) for duration >4 weeks 3
• Decompressing gastrostomy may be necessary in some cases for gastric decompression 3, 2

Step 6: Interventional Therapies for Severe Refractory Cases

Gastric Electrical Stimulation

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

Endoscopic Interventions

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

Nutritional Monitoring Requirements

• Target protein intake of 1.2-1.5 g/kg/day to address malnutrition 3, 2
• Monitor weekly weights during the first month to assess nutritional adequacy 3, 2
• Screen for micronutrient deficiencies (vitamin B12, vitamin D, iron, calcium) and supplement as needed 3
• Consider oral nutritional supplements between meals to increase caloric and protein intake 3, 2

Critical Pitfalls to Avoid

• Do NOT continue metoclopramide beyond 12 weeks without careful reassessment due to serious adverse effect risks including tardive dyskinesia 1, 3, 2
• 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, as many commonly prescribed medications worsen gastroparesis 1, 2
• Do NOT use gastrostomy (PEG) tubes in gastroparesis patients as they deliver nutrition into the dysfunctional stomach and will not bypass the emptying problem 3
• Do NOT delay tube feeding beyond 10 days of inadequate intake in patients with documented gastroparesis, as malnutrition significantly worsens outcomes 3
• In diabetic patients, do NOT neglect glycemic control optimization as hyperglycemia directly impairs gastric emptying 1, 2