Dietary and Lifestyle Modifications

The American Diabetes Association recommends implementing 5-6 small meals daily with low-fat, low-fiber content to minimize gastric distension and promote faster gastric emptying in patients with diabetes-related gastroparesis 1, 2
Focus on foods with small particle size to improve key symptoms in patients with gastroparesis, as suggested by the American Gastroenterological Association 1, 3
Replace solid food with liquids such as soups for patients with severe symptoms, according to the American College of Gastroenterology 1
Avoid foods that delay gastric emptying (high-fat, high-fiber) in patients with diabetes-related gastroparesis, as recommended by the American Heart Association 1, 2
Avoid lying down for at least 2 hours after eating to reduce symptoms in patients with diabetes-related gastroparesis, as suggested by the American College of Physicians 1

Glycemic Control

Maintain glucose levels below a certain threshold to minimize gastroparesis symptoms in patients with diabetes, according to the American Diabetes Association 2
Near-normal glycemic control implemented early can delay or prevent development of diabetic neuropathy and associated digestive complications in patients with diabetes, as recommended by the American Association of Clinical Endocrinologists 2
Be aware that gastroparesis may impact adversely on glycemic control, particularly in insulin-treated patients, as noted by the European Association for the Study of Diabetes 4

Metoclopramide (10 mg three times daily before meals) is the only FDA-approved medication for gastroparesis and should be the first-line pharmacological treatment, according to the American Gastroenterological Association 3
Initial treatment with metoclopramide should be for at least 4 weeks to determine efficacy in patients with diabetes-related gastroparesis, as recommended by the American College of Gastroenterology 1, 2
Be aware of the black box warning for tardive dyskinesia with metoclopramide use; the FDA recommends against use beyond 12 weeks, as noted by the American Medical Association 3
Erythromycin can be administered for short-term use due to tachyphylaxis in patients with diabetes-related gastroparesis, according to the Infectious Diseases Society of America 1, 3

Withdraw medications with adverse effects on gastrointestinal motility, including opioids, anticholinergics, TCAs, and GLP-1 RAs, in patients with refractory diabetes-related gastroparesis, as recommended by the American Gastroenterological Association 2, 3
Consider jejunostomy tube feeding for patients unable to maintain adequate oral intake, according to the American Society for Parenteral and Enteral Nutrition 1, 2
Decompressing gastrostomy may be necessary in some cases of severe gastroparesis, as noted by the Society of American Gastrointestinal and Endoscopic Surgeons 1, 2
Gastric electrical stimulation using a surgically implantable device has received FDA approval, though data in diabetic gastroparesis is limited, according to the American Gastroenterological Association 3

Continuing metoclopramide beyond 12 weeks without careful reassessment due to risk of tardive dyskinesia in patients with diabetes-related gastroparesis, as warned by the FDA 1
Failing to recognize medication-induced gastroparesis (e.g., from opioids, GLP-1 agonists) in patients with diabetes, according to the American Diabetes Association 1, 2
Neglecting to assess for other diabetic complications such as cardiovascular autonomic neuropathy, which often coexists with gastroparesis, as recommended by the American Heart Association 2
Overlooking the impact of gastroparesis on absorption of orally administered drugs, which may result in later or fluctuating maximal serum concentrations, as noted by the European Association for the Study of Diabetes 4

Routinely inquire about gastrointestinal symptoms in patients with diabetes, according to the American Diabetes Association 4
Evaluate effectiveness of therapy and adjust treatment as needed in patients with diabetes-related gastroparesis, as recommended by the American Association of Clinical Endocrinologists 1
Consider measuring gastric emptying by scintigraphy or stable isotope breath test in patients with suspected gastroparesis, according to the American Gastroenterological Association 4

The American Diabetes Association recommends stopping or reducing GLP-1 receptor agonists (semaglutide, dulaglutide, liraglutide) and pramlintide to improve gastric motility, though this should be balanced against their glycemic benefits 5
Erythromycin can be used short-term for diabetic gastroparesis, but it develops tachyphylaxis (loss of effectiveness) with prolonged use 5
OTC antiemetics (such as dimenhydrinate or meclizine) may reduce nausea but do not address the underlying delayed gastric emptying and can actually worsen gastroparesis through anticholinergic effects 5

In patients with an acute worsening of diabetic gastroparesis, intravenous erythromycin administered at 3 mg/kg can be used to stimulate gastric motility and relieve symptoms 6