What are the treatment options for gastroparesis?

Treatment Options for Gastroparesis

Stepwise Treatment Algorithm

Begin with dietary modifications and medication withdrawal, followed by metoclopramide as first-line pharmacologic therapy, reserving interventional approaches for refractory cases. 1, 2

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

• Implement 5-6 small, frequent meals daily instead of 3 large meals to minimize gastric distension while maximizing nutritional intake 1, 2
• Focus exclusively on low-fat, low-fiber foods with small particle size, as fat and fiber significantly delay gastric emptying 1, 2
• Replace solid foods with liquids (soups, nutritional supplements) in patients with severe symptoms, as liquids empty faster than solids 1, 2
• Use complex carbohydrates and energy-dense liquids in small volumes to maintain caloric intake 1
• Avoid lying down for at least 2 hours after eating to reduce symptom severity 1

Critical first step: Immediately discontinue all medications that worsen gastric motility, including opioids, anticholinergics, tricyclic antidepressants, GLP-1 receptor agonists, and pramlintide 2. In diabetic patients taking GLP-1 agonists, carefully weigh the risk of removing these agents against their glycemic benefits 2.

Step 2: Optimize Glycemic Control (Diabetic Gastroparesis Only)

• Achieve tight glycemic control in diabetic patients, as hyperglycemia directly impairs gastric emptying and worsens symptoms 2

Step 3: First-Line Pharmacologic Therapy

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:

• Administer for at least 4 weeks to determine efficacy in diabetic gastroparesis 1, 3
• Limit total duration to maximum 12 weeks due to FDA black box warning for tardive dyskinesia and extrapyramidal symptoms 1, 2
• Reserve metoclopramide for severe cases unresponsive to dietary modifications 2
• For severe acute symptoms, initiate with IV metoclopramide 10 mg administered slowly over 1-2 minutes, then transition to oral therapy 3

Step 4: Antiemetic Therapy for Symptom Control

• Add phenothiazines (prochlorperazine, trimethobenzamide, promethazine) for nausea and vomiting control 1
• Use 5-HT3 receptor antagonists (ondansetron, granisetron) on an as-needed basis for refractory nausea 1, 2
• These agents control symptoms but do not improve gastric emptying 2

Step 5: Second-Line Pharmacologic Options

Erythromycin (when metoclopramide fails or is not tolerated) 1, 2, 4:

• Effective only for short-term use due to rapid development of tachyphylaxis 1, 2, 4
• Administer 900 mg/day orally or intravenously 4
• Particularly useful in acute settings or when IV therapy is needed 4
• Major limitation: loses effectiveness within days to weeks of continuous use 1, 2, 4

Domperidone (not FDA-approved in United States) 1, 2:

• Available in Canada, Mexico, and Europe as an alternative prokinetic agent 1, 2
• Dopamine D2 receptor antagonist with fewer central nervous system side effects than metoclopramide 2

Step 6: Nutritional Support for Inadequate Oral Intake

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

• Jejunostomy (not gastrostomy) 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
• Start continuous feeding at 10-20 mL/hour and gradually advance over 5-7 days to reach target intake 1
• Never use gastrostomy (PEG) tubes in gastroparesis—they deliver nutrition into the dysfunctional stomach and will not improve symptoms 1

Consider decompressing gastrostomy in addition to feeding jejunostomy for patients with severe refractory vomiting 1.

Step 7: Interventional Therapies for Severe Refractory Cases

Gastric electrical stimulation (GES) 2, 5:

• FDA-approved on humanitarian device exemption for severe symptoms refractory to dietary and medical management 1, 2
• May reduce weekly vomiting frequency and need for nutritional supplementation based on open-label studies 5
• Efficacy is variable; reserve for individuals with severe refractory symptoms 2

Gastric per-oral endoscopic myotomy (G-POEM) 1, 2:

• Consider only in severe refractory cases at tertiary care centers with expertise in treating gastroparesis 1, 2

Intrapyloric botulinum toxin injection 1, 2:

• Not recommended—placebo-controlled studies show no benefit over placebo 1, 2

Parenteral nutrition 1:

• Reserve as absolute last resort only when jejunal feeding fails or is contraindicated 1
• Associated with higher complication rates including catheter-related sepsis 1

Critical Pitfalls to Avoid

• Do not continue metoclopramide beyond 12 weeks without careful reassessment due to cumulative risk of irreversible tardive dyskinesia 1, 2
• Do not overlook medication withdrawal as the critical first step—many commonly prescribed medications (opioids, GLP-1 agonists) directly worsen gastroparesis 1, 2
• Do not use gastrostomy tubes in gastroparesis patients—they fail to 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 pursue intrapyloric botulinum toxin injection—evidence clearly shows no benefit over placebo 1, 2
• In diabetic patients, do not neglect glycemic control optimization, as hyperglycemia directly impairs gastric emptying 2

Monitoring Nutritional Status

• Perform weekly weight measurements during initial management 1
• Monitor for micronutrient deficiencies, especially vitamin B12, vitamin D, iron, and calcium 1
• Assess mid-arm circumference to monitor for malnutrition and sarcopenia 1
• Target protein intake of 1.2-1.5 g/kg/day and 25-30 kcal/kg/day for malnourished patients 1