What medical therapies work for gastroparesis?
EVIDENCE-BASED ANSWER:
It’s unclear if there are any highly effective medications for gastroparesis (TABLE1-10). Metoclopramide improves the sense of fullness by about 40% for as long as 3 weeks, may improve nausea, and doesn’t affect vomiting or anorexia (strength of recommendation [SOR]: B, small randomized controlled trial [RCT]).
Whether or not erythromycin has an effect on symptoms is unclear (SOR: C, conflicting trials and expert opinion).
Domperidone may improve quality of life (by 2%) for as long as a year, but its effect on symptoms is also unclear (SOR: C, small RCTs).
Cisapride may not be effective for symptom relief (SOR: C, small conflicting RCTs), and levosulpiride is likely similar to cisapride (SOR: C, single small crossover trial).
Nortriptyline (SOR: B, single RCT) and intrapyloric botulinum toxin A (SOR: B, small RCT and crossover trial) aren’t effective for symptom relief.
Levosulpiride. One crossover study compared 25 mg levosulpiride with 10 mg cisapride (both given orally 3 times a day) on gastroparesis symptoms and gastric emptying. Each medication was given for one month (washout duration not given). The study found similar efficacy between levosulpiride and cisapride in terms of improvement in gastric emptying rates and total symptom scores.7 No studies compare levosulpiride to placebo.
Nortriptyline. A multicenter, parallel-group, double-blind RCT comparing 75 mg/d nortriptyline for 15 weeks with placebo in adult patients with moderate to severe symptoms of idiopathic gastroparesis for at least 6 months found that nortriptyline didn’t improve symptoms.8
Botulinum toxin A. An RCT comparing a single injection of 200 units intrapyloric botulinum toxin A with placebo in adult patients with severe gastroparesis symptoms found that botulinum toxin A didn’t result in symptomatic improvement.9 A crossover trial comparing 100 units monthly intrapyloric botulinum toxin A for 3 months with placebo in patients with gastroparesis found that neither symptoms nor rate of gastric emptying changed with the toxin.10
RECOMMENDATIONS
The 2013 guidelines from the American College of Gastroenterology list metoclopramide as the first-line agent for gastroparesis requiring medical therapy, followed by domperidone and then erythromycin (all based on “moderate quality evidence”). Antiemetic agents are also recommended for symptom control.11
