From the Guidelines
Management of gastroparesis should prioritize a comprehensive approach, including dietary modifications and medications, with metoclopramide being the only FDA-approved medication, and its use should be limited to severe cases due to potential adverse effects, as recommended by the most recent guidelines 1.
Key Components of Management
- Dietary modifications: small, frequent, low-fat, low-fiber meals with a greater proportion of liquid calories, and foods with small particle size may improve symptoms 1
- Medications: + Prokinetics: metoclopramide (5-20 mg tid-qid) and domperidone (10-20 mg orally 3-4 times daily) 2 + Antiemetics: ondansetron (4-8 mg bid or tid) or prochlorperazine (5-10 mg qid) 2 + Pain management: low-dose tricyclic antidepressants like amitriptyline (25-100 mg/day) 2 ### Interventional Approaches
- Gastric electrical stimulation: approved under a Humanitarian Device Exemption (HDE) for severe cases refractory to medical therapy 2
- Botulinum toxin injection into the pylorus: may be beneficial for some patients, but evidence is limited 2
- Surgical options: pyloroplasty or other procedures may be considered in severe cases refractory to medical therapy 2 ### Individualized Approach
- The management approach should be tailored to the individual patient's symptom severity, underlying etiology, and response to therapy, with regular follow-up to adjust treatment as needed 1
From the FDA Drug Label
For the Relief of Symptoms Associated with Diabetic Gastroparesis (Diabetic Gastric Stasis) If only the earliest manifestations of diabetic gastric stasis are present, oral administration of metoclopramide may be initiated. However, if severe symptoms are present, therapy should begin with metoclopramide injection (IM or IV) INDICATIONS AND USAGE Diabetic Gastroparesis (Diabetic Gastric Stasis) Metoclopramide is indicated for the relief of symptoms associated with acute and recurrent diabetic gastric stasis.
Management of Gastroparesis: Metoclopramide is indicated for the relief of symptoms associated with acute and recurrent diabetic gastric stasis. The treatment approach depends on the severity of symptoms.
- For mild symptoms, oral administration of metoclopramide may be initiated.
- For severe symptoms, therapy should begin with metoclopramide injection (IM or IV) 3, 4.
From the Research
Management of Gastroparesis
The management of gastroparesis involves several key components, including:
- Correction of nutritional state, relief of symptoms, improvement of gastric emptying, and glycemic control in diabetics 5
- Assessment and management of patient nutritional state through oral dietary modifications, enteral nutrition via jejunostomy tube, or parenteral nutrition if necessary 5
- Medical treatment with prokinetic and antiemetic therapies, including metoclopramide, domperidone, and erythromycin 5, 6, 7
- Consideration of novel pharmacotherapies, such as 5-HT4 serotonin receptor agonists and dopamine D2 receptor antagonists 6, 7
- Use of gastric electrical stimulation, which may relieve symptoms and improve gastric emptying 5, 7
Treatment Options
Treatment options for gastroparesis include:
- Prokinetic agents, such as metoclopramide and domperidone, which are the mainstay of treatment 6, 7
- Antiemetic agents, such as phenothiazines, serotonin antagonists, and butyrophenones, which may relieve nausea and vomiting 6, 7
- Novel agents, such as ghrelin, TZP-101, and TZP-102, which are currently in development 6
- Surgical interventions, such as gastrostomy and jejunostomy, which are considered a last resort 7
Drug-Drug Interactions
The treatment of gastroparesis often involves the co-administration of multiple pharmacological agents, which can lead to potential drug-drug interactions (DDIs) 8. These interactions can result in undesired clinical outcomes, such as changes in systemic drug levels or increased risk of adverse effects. It is essential to consider the potential for DDIs when managing gastroparesis patients, particularly those with diabetes who may be taking multiple medications 8.