New guidelines will put focus on how to manage gastroparesis. Patients with this delayed gastric emptying often struggle to relieve symptoms like bloating, early satiety, vomiting, etc. Causes include diabetes, abdominal surgery and medications that slow GI motility (anticholinergics, opioids, etc).
Continue to follow a stepwise approach. Emphasize dietary changes. For example, suggest smaller, more frequent meals with less fat and fiber, or liquid nutrition if needed. Optimize diabetes management if needed. Delayed gastric emptying may be worsened by high blood glucose, such as over 250 mg/dL. If possible, deprescribe medications that can delay gastric emptying. For example, GLP-1 agonists (Ozempic, etc) may be used for CV benefit in type 2 diabetes, but can worsen gastroparesis symptoms. Consider an SGLT2 inhibitor (Jardiance, etc) for CV benefit instead.
If these steps aren’t enough, try oral metoclopramide (Primperan) to increase GI motility, starting with 5 mg TID before meals. Don’t exceed metoclopramide 40 mg/day, or 12 weeks of use. Keep in mind, labeling warns about risk of tardive dyskinesia. Advise patients to promptly report involuntary movements. Also evaluate ways to minimize overall exposure, such as trying a metoclopramide “holiday” at least every 12 weeks or stepping down to a lower dose (BID, etc). Don’t go to Gimoti (metoclopramide) nasal spray instead (NOT available in Eygpt), there’s not good evidence it works better or is safer than oral. If metoclopramide doesn’t work or isn’t tolerated, think of oral erythromycin, starting with 250 mg TID. It also improves gastric emptying, but its effectiveness usually drops after 4 weeks. If needed for nausea or vomiting, try an antiemetic (ondansetron, etc). But these don’t improve gastric emptying. Or consider a low-dose tricyclic for refractory nausea or vomiting. Lean toward nortriptyline for fewer anticholinergic effects.
REFERENCES
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Camilleri M, Kuo B, Nguyen L, Vaughn VM, Petrey J, Greer K, Yadlapati R, Abell TL. ACG Clinical Guideline: Gastroparesis. Am J Gastroenterol. 2022 Aug 1;117(8):1197-1220. Available at: https://pubmed.ncbi.nlm.nih.gov/35926490
Zheng T, Camilleri M. Management of Gastroparesis. Gastroenterol Hepatol (N Y). 2021 Nov;17(11):515-525. Available at: https://pubmed.ncbi.nlm.nih.gov/35466306
Drug Approval Package: GIMOTI. [online] Available at: https://www.accessdata.fda.gov/drugsatfda_docs/nda/2021/209388Orig1s000TOC.cfm