What are the treatment options for diabetic gastroparesis?

Treatment of Diabetic Gastroparesis

Initial Dietary Management

Begin with low-fat, low-fiber meals consisting of 5-6 small, frequent feedings per day, as this is the cornerstone of gastroparesis management. 1, 2

• Replace solid foods with liquids (soups, nutritional shakes) in patients with severe symptoms to facilitate gastric emptying 1, 2
• Focus on foods with small particle size and complex carbohydrates to improve key symptoms 1, 2
• Limit fat intake to less than 30% of total calories to promote gastric emptying 1
• Use energy-dense liquids in small volumes to maintain adequate caloric intake 1, 2
• Avoid lying down for at least 2 hours after eating to reduce symptom severity 2

Optimize Glycemic Control and Medication Review

Aggressively optimize blood glucose control, as hyperglycemia directly worsens gastric emptying and perpetuates symptoms. 2

• Consider insulin pump therapy in patients with type 1 diabetes for better glycemic stability 2
• Immediately discontinue medications that worsen gastroparesis: opioids, anticholinergics, tricyclic antidepressants, and GLP-1 receptor agonists 1, 2, 3
• Balance the risk of removing GLP-1 receptor agonists against their glycemic benefits, though withdrawal should be strongly considered 2, 3

First-Line Pharmacologic Therapy: Metoclopramide

Metoclopramide 10 mg three times daily before meals is the only FDA-approved medication for gastroparesis and should be the first pharmacologic choice. 1, 2, 4

• Initiate treatment for at least 4 weeks to determine efficacy in diabetic gastroparesis 1, 2
• Strictly limit use to ≤12 weeks due to FDA black box warning for tardive dyskinesia risk 1, 2, 3
• If severe symptoms are present, therapy may begin with IV metoclopramide (10 mg slowly over 1-2 minutes), then transition to oral when symptoms subside 4
• Adjust insulin dosage or timing when starting metoclopramide, as it influences food delivery to the intestines and absorption rate 4

Critical Safety Considerations for Metoclopramide

• Acute dystonic reactions occur in approximately 0.2% of patients, with higher incidence in patients under 30 years 3
• Tardive dyskinesia occurs in approximately 5% of young patients per year, with higher rates in older patients on prolonged therapy 3
• If acute dystonic reactions occur, inject 50 mg diphenhydramine intramuscularly 4
• Never continue metoclopramide beyond 12 weeks without careful reassessment and documentation of ongoing benefit versus tardive dyskinesia risk 1, 2, 3

Second-Line Pharmacologic Options

When metoclopramide fails or is not tolerated:

• Erythromycin can be used for short-term management, but tachyphylaxis develops rapidly, limiting its effectiveness 1, 2
• Phenothiazines (prochlorperazine, trimethobenzamide, promethazine) for nausea and vomiting control 1, 2
• Serotonin (5-HT3) receptor antagonists (ondansetron) for refractory nausea 1, 2
• Domperidone as an alternative prokinetic (not FDA-approved in the US, but available in Canada, Mexico, and Europe) 1

Management of Refractory Gastroparesis

Nutritional Support

For patients unable to maintain adequate oral intake (below 50-60% of energy requirements for more than 10 days) despite dietary modifications and pharmacologic therapy, initiate jejunostomy tube feeding to bypass the stomach. 1, 2

• Target 25-30 kcal/kg/day to promote weight restoration 1, 2
• Aim for protein intake of 1.2-1.5 g/kg/day to address malnutrition 1
• Use nasojejunal tube for anticipated duration <4 weeks or trial period 1
• Use percutaneous endoscopic jejunostomy (PEJ) for anticipated duration >4 weeks 1
• Do not use gastrostomy (PEG) tubes in gastroparesis patients as they deliver nutrition into the dysfunctional stomach and will not bypass the emptying problem 1
• Start continuous feeding at low flow rates (10-20 mL/hour), gradually advancing over 5-7 days to reach target intake 1

Advanced Interventions for Medically Refractory Cases

Gastric electrical stimulation (GES) could be an option for gastroparesis patients with refractory/intractable nausea and vomiting who have failed standard therapy, are not on opioids, and do not have abdominal pain as the predominant symptom. 5

• Persistent abdominal pain is not an indication for GES, and opioid use is a contraindication 5
• Refractory symptoms of shorter duration are more likely to respond than prolonged intractable symptoms 5

Gastric per-oral endoscopic myotomy (G-POEM) may be considered in severe, refractory cases, but should only be performed at tertiary care centers using a team approach of experts with extensive experience. 5, 1, 2

• Two separate multicenter trials noted improvement in symptoms and reduction in gastric emptying times 5
• Randomized, sham-controlled studies do not exist, and long-term follow-up data are not available 5
• G-POEM has the theoretical potential to induce dumping syndrome, which has a deleterious effect on food tolerance and quality of life 5

Interventions NOT Recommended

Available data argue against use of intrapyloric botulinum toxin in refractory gastroparesis, except in clinical trials. 5

• Two larger placebo-controlled studies showed no benefit over placebo 5
• Although generally safe, evidence does not support routine use 5

Transpyloric stent placement should be considered investigational in refractory gastroparesis for the lack of data from prospective, sham-controlled trials and concerns over stent migration. 5

Nutritional Monitoring

• Monitor weekly weights to assess nutritional adequacy 1, 2
• Screen for micronutrient deficiencies (vitamin B12, vitamin D, iron, calcium) and supplement as needed 1
• Consider oral nutritional supplements between meals to increase caloric and protein intake 1, 2
• Assess for sarcopenia, which may be masked by fluid retention 1

Critical Pitfalls to Avoid

• Do not overlook medication-induced gastroparesis from opioids or GLP-1 agonists 1, 2, 3
• Do not delay tube feeding beyond 10 days of inadequate intake in patients with documented gastroparesis, as malnutrition significantly worsens outcomes 1
• Avoid high-fat, high-fiber foods that will exacerbate delayed gastric emptying 1, 2
• Do not use gastrostomy tubes in gastroparesis as they do not bypass the gastric emptying problem 1
• Exercise caution when using metoclopramide in hypertensive patients, as it releases catecholamines 4
• Adjust insulin timing when starting metoclopramide to prevent hypoglycemia, as gastric emptying acceleration may cause insulin to act before food absorption 4