From the Guidelines
For a patient with potential diabetic gastroparesis who is on oxempic and has poorly controlled diabetes (HbA1c 11-12%), I recommend temporarily discontinuing oxempic to determine if it's causing the nausea, as GLP-1 RAs like oxempic can have adverse effects on gastrointestinal motility 1. This approach is based on the latest guidelines from the Diabetes Care journal, which suggests that withdrawing drugs with adverse effects on gastrointestinal motility, including GLP-1 RAs, may improve intestinal motility 1. During this period, the following steps can be taken:
- Implement dietary modifications, such as a low-fiber, low-fat eating plan provided in small frequent meals with a greater proportion of liquid calories, as this may be useful in managing gastroparesis symptoms 1
- Improve glycemic control with alternative diabetes medications, such as basal insulin plus rapid-acting insulin or non-GLP-1 oral agents
- Consider gastroparesis-specific treatments, such as metoclopramide 5-10mg before meals (maximum 12 weeks due to tardive dyskinesia risk) or domperidone 10mg three times daily (if available) 1 After 2-4 weeks off oxempic, reassess symptoms to determine the next course of action. If nausea resolves, consider alternative diabetes treatments; if symptoms persist, perform gastric emptying studies to confirm gastroparesis diagnosis. For confirmed gastroparesis, consider erythromycin 50-100mg three times daily before meals, or other treatment options, and prioritize aggressive diabetes management to improve glycemic control, as this often improves gastroparesis symptoms 1.
From the FDA Drug Label
Severe Gastrointestinal Adverse Reactions: Use has been associated with gastrointestinal adverse reactions, sometimes severe. OZEMPIC is not recommended in patients with severe gastroparesis (5. 7). Gastrointestinal Adverse Reactions In the pool of placebo-controlled trials, gastrointestinal adverse reactions occurred more frequently among patients receiving OZEMPIC than placebo (placebo 15.3%, OZEMPIC 0.5 mg 32.7%, OZEMPIC 1 mg 36.4%).
Diabetic Gastroparesis Treatment: The patient's nausea may be related to oxempic use or diabetic gastroparesis. Given the patient's chronically elevated HgA1c levels, it is essential to consider the potential for severe gastrointestinal adverse reactions associated with oxempic use.
- Next Steps:
- Monitor the patient's gastrointestinal symptoms and adjust the oxempic dose or consider alternative treatments if severe gastrointestinal adverse reactions occur.
- Consider evaluating the patient for diabetic gastroparesis and managing the condition accordingly.
- Reduce the dose of concomitantly administered insulin secretagogue (such as sulfonylureas) or insulin to reduce the risk of hypoglycemia 2.
- Patients with a history of diabetic retinopathy should be monitored 2.
From the Research
Diabetic Gastroparesis Treatment
The patient's symptoms of nausea and high HgA1c levels (11 and 12s) suggest diabetic gastroparesis, a complication of long-standing type 1 and type 2 diabetes mellitus 3. The treatment approaches for diabetic gastroparesis include:
- Improving glucose control with insulin
- Prescribing antinauseant drugs, prokinetic agents, and gastric electric stimulation 3
- Dietary modifications, supplemental oral nutrition, and antiemetic and prokinetic medications 4
- Venting gastrostomy or jejunostomy and/or gastric electrical stimulation for patients with more severe symptoms 4
Medication Options
Metoclopramide is the only drug approved by the Food and Drug Administration for diabetic gastroparesis, but it carries a black box warning for use >12 weeks due to the risk of tardive dyskinesia (TD) 5. Other prokinetic agents such as domperidone and erythromycin may also be used, but they have unwanted side effects and numerous drug interactions 6. Newer therapeutic approaches include ghrelin receptor agonists and selective 5-hydroxytryptamine receptor agonists 4.
Next Steps
To determine the best course of treatment, it is essential to:
- Assess the patient's symptoms and glycemic control
- Consider the potential benefits and risks of different treatment options
- Monitor the patient's response to treatment and adjust as needed 7
- Optimize glycemic management, often involving customizing insulin delivery using basal-bolus insulin and technology, including sensor-augmented pumps and continuous glucose monitoring systems 7