What are the treatments for idiopathic gastroparesis with significantly delayed gastric emptying?

From the Guidelines

Idiopathic gastroparesis with significantly delayed gastric emptying is typically treated with a combination of medications, endoscopic procedures, and dietary adjustments.

Treatment Options

• Medications to accelerate gastric emptying: Metoclopramide 1 is the only FDA-approved medication for gastroparesis, but its use is recommended for no more than 12 weeks due to the risk of serious adverse effects 1. Other options include domperidone (available outside the U.S.) and erythromycin, which is only effective for short-term use due to tachyphylaxis 1.
• Medications for nausea and vomiting: Ondansetron, granisetron, and prochlorperazine are commonly used to manage symptoms of nausea and vomiting 1.
• Endoscopic procedures: Gastric peroral endoscopic myotomy (G-POEM) is a minimally invasive option for severe gastroparesis, particularly for patients with primarily nausea and vomiting 1.
• Gastric electrical stimulation: This treatment option is approved by the FDA for individuals with severe symptoms that are refractory to other treatments, but its efficacy is variable 1.
• Dietary adjustments: Patients with gastroparesis are often advised to follow a diet that is low in fat and fiber, and to eat smaller, more frequent meals throughout the day.

Patient Selection for G-POEM

• Patients with solid-phase gastric retention of >20% at 4 hours on a gastric emptying scan (GES) are considered good candidates for G-POEM 1.
• Patients with moderate-to-severe symptoms, as measured by the Gastroparesis Cardinal Symptom Index (GCSI), may also be considered for G-POEM 1.
• The decision to offer G-POEM should be based on the full clinical picture, taking into account the patient's symptoms, gastric emptying delay, and response to previous treatments 1.

From the Research

Treatments for Idiopathic Gastroparesis

The treatments for idiopathic gastroparesis with significantly delayed gastric emptying include:

• Dietary and lifestyle measures 2, 3, 4
• Pharmacological interventions, such as:
  • Prokinetic agents (e.g. metoclopramide, domperidone, erythromycin) 5, 6
  • Antiemetic agents (e.g. aprepitant) 6
  • Fundic relaxants (e.g. acotiamide, buspirone) 6
• Interventions that focus on adequate nutrient intake, such as:
  • Nasoduodenal tube 2
  • Percutaneous gastrostomy 2
  • Jejunostomy 2
• Endoscopic pyloromyotomy, which appears promising for symptoms of nausea and vomiting 6
• Gastric electrical stimulation, which is a relatively new treatment strategy 5, 2
• Novel pharmacotherapies, such as relamorelin and prucalopride, which are currently in development 5, 6

Management Strategies

Management strategies for idiopathic gastroparesis include:

• Correction of malnutrition, dehydration, and electrolyte imbalance 5, 4
• Relief of symptoms using prokinetic and antiemetic agents 5, 2, 6
• Optimization of glycaemic control in patients with diabetes 5
• Identification and treatment of the underlying cause of delayed gastric emptying, if possible 4