Gastroparesis Management

Introduction to Gastroparesis Management

Gastroparesis management involves a step-wise approach, starting with optimization of dietary management and glycemic control, followed by the use of medications and finally considering combination therapy or referral for advanced interventions for refractory cases, as recommended by the American Gastroenterological Association 1

The American Gastroenterological Association recommends tricyclic antidepressants (TCAs) as first-line treatments for pain associated with gastroparesis, with high-quality evidence supporting their use, particularly in patients with diabetic neuropathic pain 2, 1
TCAs should be started with low doses and titrated gradually to minimize anticholinergic side effects, with caution in patients ≥65 years due to anticholinergic side effects 2
Duloxetine (60-120 mg daily) has demonstrated efficacy for diabetic neuropathic pain and may be considered for patients who cannot tolerate TCAs, with common side effects including nausea or constipation 1
Gabapentin (>1200 mg daily in divided doses) and pregabalin (150-600 mg daily in divided doses) have shown benefit for neuropathic pain, with common side effects including dizziness, somnolence, weight gain, and peripheral edema 1
Mirtazapine has shown improvement in refractory nausea, vomiting, and early satiation in gastroparesis patients 1
Tertiary amines (amitriptyline, imipramine) may be more effective than secondary amines (nortriptyline) for pain control in gastroparesis patients, particularly those with diabetic gastroparesis and pain as a predominant symptom 1

Opioid analgesics (morphine, oxycodone, hydromorphone) should never be used for gastroparesis pain as they further delay gastric emptying, increase risk of narcotic bowel syndrome, and create potential for addiction and tolerance 1, 3, 4
Other medications that can worsen gastroparesis and should be avoided or minimized include anticholinergics, GLP-1 receptor agonists, and pramlintide 3, 4

Small, frequent meals with low-fiber, low-fat content, and a higher proportion of liquid calories, with foods having small particle size may be beneficial for patients with gastroparesis, as recommended by the American Gastroenterological Association and the American Diabetes Association 2, 3
The American Diabetes Association recommends small, frequent meals, low-fat, low-fiber diet, and more liquid calories to improve key symptoms in gastroparesis patients 3

Gastric electrical stimulation (GES) may be considered for refractory cases with predominant nausea and vomiting, but is not primarily indicated for pain management 1
Pylorus-directed therapies may be considered in specialized centers for cases with severe emptying delay 1
Metoclopramide (10mg orally 30 minutes before meals and at bedtime) is the only FDA-approved medication for gastroparesis, but its use is limited to 12 weeks due to risk of tardive dyskinesia 4
Erythromycin (40-250mg orally three times daily) can be used as an alternative prokinetic agent in gastroparesis patients 4

Identify predominant symptoms to determine if pain is the primary symptom or if other symptoms like nausea and vomiting predominate 1
First-line therapy should start with low-dose TCA (e.g., amitriptyline) for pain predominant gastroparesis, or duloxetine (SNRI) if not tolerated or contraindicated 1
Second-line therapy may involve adding or switching to gabapentin or pregabalin if inadequate response to first-line agents, with assessment of response at 2-4 week intervals 1
Response to pain management should be assessed at 2-4 week intervals, and medications should be switched if there is an inadequate response or intolerable side effects 1