What is the recommended inpatient management for diabetic gastroparesis?

Inpatient Management of Diabetic Gastroparesis

Immediate Assessment and Initial Stabilization

For hospitalized patients with diabetic gastroparesis, begin with IV metoclopramide 10 mg administered slowly over 1-2 minutes, which may be required for up to 10 days before transitioning to oral therapy, while simultaneously implementing dietary modifications and optimizing glycemic control. 1, 2

Medication Review and Discontinuation

• Immediately discontinue opioids, as opioid-induced gastroparesis may be reversible 3, 4
• Stop or reduce GLP-1 receptor agonists and pramlintide, though balance this against their glycemic benefits 3, 4, 5
• Avoid anticholinergics, tricyclic antidepressants, and possibly DPP-4 inhibitors 4

Pharmacologic Management

First-Line Prokinetic Therapy

• Administer metoclopramide 10 mg IV slowly over 1-2 minutes for severe symptoms, which is the only FDA-approved medication for gastroparesis 3, 1, 2
• Continue IV administration for up to 10 days until symptoms subside, then transition to oral metoclopramide 10 mg three times daily before meals 1, 2
• Limit total metoclopramide use to ≤12 weeks due to FDA black box warning for tardive dyskinesia 3, 4, 5
• Monitor regularly for extrapyramidal symptoms including acute dystonic reactions (0.2% incidence), drug-induced parkinsonism, and akathisia 5
• Keep diphenhydramine 50 mg available for immediate IM injection if acute dystonic reactions occur 1, 2

Antiemetic Therapy

• Use phenothiazines (prochlorperazine, trimethobenzamide, promethazine) for nausea and vomiting 3
• Administer serotonin (5-HT3) receptor antagonists like ondansetron for refractory nausea 3, 5

Alternative Prokinetic Options

• Consider erythromycin IV for short-term use, though tachyphylaxis limits prolonged efficacy 3
• Domperidone may be an option if available (not FDA-approved in the US) 3

Nutritional Management

Dietary Modifications for Mild-Moderate Cases

• Implement 5-6 small, low-fat (<30% of calories), low-fiber meals daily to minimize gastric distension 3, 4
• Replace solid foods with liquids such as soups, particularly in severe cases 3, 4
• Focus on complex carbohydrates and energy-dense liquids in small volumes 3
• Prioritize foods with small particle size to improve symptoms 3, 4
• Avoid high-fat and high-fiber foods that delay gastric emptying 3, 4

Nutritional Support for Severe Cases

• Target 25-30 kcal/kg/day and protein intake of 1.2-1.5 g/kg/day for malnourished patients 3, 4
• Monitor for micronutrient deficiencies, especially vitamin B12, vitamin D, iron, and calcium 3
• Consider oral nutritional supplements between meals to increase caloric and protein intake 3

Enteral Nutrition Criteria

Initiate jejunostomy tube feeding if oral intake remains below 50-60% of energy requirements for more than 10 days despite dietary modifications and medical therapy 3

Tube Feeding Selection Algorithm

• Use jejunostomy tube feeding as the preferred route because it bypasses the dysfunctional stomach entirely 3, 4
• Place nasojejunal tube for anticipated duration <4 weeks or trial period 3
• Place percutaneous endoscopic jejunostomy (PEJ) for anticipated duration >4 weeks 3, 4
• Never use gastrostomy (PEG) tubes in gastroparesis patients, as they deliver nutrition into the dysfunctional stomach and will not bypass the emptying problem 3, 4

Feeding Protocol

• Start continuous feeding at 10-20 mL/hour due to limited intestinal tolerance 3
• Gradually advance over 5-7 days to reach target intake 3
• Use standard whole protein formula initially 3
• Reassess weekly during first month, then monthly thereafter 3, 4

Glycemic Control Optimization

• Target near-normal glycemic control, as hyperglycemia itself delays gastric emptying and worsens symptoms 6, 4
• Consider insulin pump therapy for patients with type 1 diabetes and gastroparesis 4
• Recognize that gastroparesis may impact glycemic control adversely, particularly in insulin-treated patients, creating a bidirectional relationship 6, 7

Management of Refractory Cases

Advanced Interventions

• Consider decompressing gastrostomy for persistent vomiting despite jejunal feeding 3
• Reserve parenteral nutrition only when jejunal feeding fails or is contraindicated, as it carries higher complication rates including catheter-related sepsis 3
• Gastric electrical stimulation (GES) may be an option for refractory nausea and vomiting in patients who have failed standard therapy, are not on opioids, and do not have abdominal pain as the predominant symptom 3
• Gastric per-oral endoscopic myotomy (G-POEM) may be considered in severe cases, but only at tertiary care centers with extensive experience 3
• Do not use intrapyloric botulinum toxin except in clinical trials, as available data argue against its use 3

Critical Pitfalls to Avoid

• Do not continue metoclopramide beyond 12 weeks without careful reassessment due to cumulative tardive dyskinesia risk (approximately 5% per year in young patients, higher in older patients) 3, 4, 5
• Do not place gastrostomy tubes in gastroparesis patients, as they worsen the problem by delivering nutrition into the dysfunctional stomach 3, 4
• Do not delay jejunal tube feeding beyond 10 days of inadequate intake in documented gastroparesis, as malnutrition significantly worsens outcomes 3, 4
• Do not overlook medication-induced gastroparesis from opioids or GLP-1 agonists, as it may be reversible 3, 4
• Avoid lying down for at least 2 hours after eating to reduce symptoms 3
• Be aware that patients on concomitant psychotropic medications have especially high risk for neuroleptic malignant syndrome with metoclopramide 5

Monitoring Parameters

• Perform weekly weight measurements during the first month, then monthly 3, 4
• Monitor for signs of micronutrient deficiencies 3, 4
• Regularly assess for extrapyramidal symptoms in patients on metoclopramide 5
• Evaluate mid-arm circumference to monitor for malnutrition 3
• Screen for sarcopenia, which may be masked by fluid retention 3