TABLE 3

Management strategies for gastroparesis

Exclude iatrogenic causes
(eg, opioids, surgery, glucagon-like peptide 1 receptor agonists)
Diet modification
Small-particle diet to improve symptom relief and facilitate gastric emptying
Pharmacologic therapy
DosageSide effects
Prokinetics
 Metoclopramidea10 mg 3 times a day, 30 minutes before meals, for a maximum of 3 months, or 70-μL spray 30 minutes before meals and at bedtime for 2–8 weeksExtrapyramidal symptoms (1%–25%, higher in elderly and young), tardive dyskinesia (around 0.1% per 1,000 patient-years)
 Erythromycin250 mg 3 times a day for 1 to 2 weeksTachyphylaxis after 4 weeks
 Domperidoneb10 mg 3 times a dayQTc interval prolongation (6%)
Antiemetics
 5-HT3 receptor antagonists (granisetron, ondansetron)Same dosage as that used to manage nausea or emesis, or as needed per patientQTc interval prolongation, second-degree heart block (< 1%)
 Neurokinin antagonists (aprepitant, tradipitant)Aprepitant dose tested in clinical trials is 125 mg once dailyFatigue, constipation (> 10%)
Neuromodulators
 LevosulpirideStart with minimum effective doseSedation, hypotension, dyskinesia
 BuspironeStart with minimum effective doseDizziness, drowsiness
 MirtazapineStart with minimum effective doseSomnolence, xerostomia, weight gain
 HaloperidolStart with minimum effective doseExtrapyramidal symptoms
Nonpharmacologic therapies
Gastric electrical stimulation (“gastric pacemaker”), acupuncture
Pyloric interventions
Endoscopic functional luminal imaging probeUsed to evaluate pyloric function and predict treatment outcomes following gastric peroral endoscopic myotomy
Intrapyloric injection of botulinum toxinNot recommended
Laparoscopic (Heineke-Mikulicz) pyloroplastySafe and enhances gastric emptying with short-term improvement in symptoms
Gastric peroral endoscopic myotomyImproves gastric emptying and is equivalent to laparoscopic pyloroplasty

  • ↵aOnly medication approved by US Food and Drug Administration (FDA) for gastroparesis; nasal spray is FDA-approved for diabetic gastroparesis.

  • ↵bAvailable through the FDA’s program for expanded access to investigational drugs.