Drug therapy for gastroparesis

A prokinetic drug is first-line drug therapy for gastroparesis. Use:

domperidone 10 mg orally, 3 times daily before meals¹ Therapeutic Goods Administration, 2012. domperidone domperidone domperidone

If domperidone is ineffective, metoclopramide may be considered, but it should be stopped if symptoms do not improveVijayvargiya, 2019. Metoclopramide should not be used for longer than 5 days² Therapeutic Goods Administration, 2015.

In the past, cisapride (a 5-HT₄ receptor agonist with prokinetic properties) was used for gastroparesis; however, at the time of writing, it is not commonly used because it has significant adverse effects (eg cardiac arrythmia) and limited availability³. Prucalopride is an alternative 5-HT₄ receptor agonist with prokinetic properties that may be used to treat gastroparesis, but it has not been well studied in gastroparesis⁴ Vijayvargiya, 2019.

Erythromycin has prokinetic properties via motilin receptors and may be used under specialist advice in patients who have failed other therapies. However, tachyphylaxis develops with chronic use, and erythromycin may exacerbate upper gastrointestinal symptoms, especially at higher doses. Doses of erythromycin for gastroparesis are generally lower than antibiotic doses. Treatment may need to be commenced intravenouslyStrijbos, 2019.

Severe nausea caused by gastroparesis may not respond to prokinetic drugs. Treat with dietary modifications and, if required, antiemetic therapy. In the past, tricyclic antidepressants were used to treat nausea caused by gastroparesis; however, a randomised controlled trial of nortriptyline in idiopathic gastroparesis did not demonstrate improvement⁵ Parkman, 2013.

Other therapies for gastroparesis have limited evidence—seek expert advice.

¹ Higher doses of domperidone may be used by specialists with appropriate monitoring for adverse effects. Evidence shows an increased risk of serious cardiac adverse effects (ventricular arrhythmias, sudden cardiac death) from domperidone at doses over 30 mg daily, and in patients older than 60 years. For more information, see the Australian Therapeutic Goods Administration (TGA) Medicines Safety Update.Return

² For more information see the Medicines Safety Update on the Australian Therapeutic Goods Administration (TGA) website.Return

³ At the time of writing, cisapride is not registered for use in Australia but is available via the Special Access Scheme or compounding pharmacies.Return

⁴ At the time of writing, prucalopride is not approved by the Australian Therapeutic Goods Administration (TGA) for the treatment of gastroparesis. See the TGA website for current information.Return

⁵ Parkman HP, Van Natta ML, Abell TL, McCallum RW, Sarosiek I, Nguyen L, et al. Effect of nortriptyline on symptoms of idiopathic gastroparesis: the NORIG randomized clinical trial. JAMA 2013;310(24):2640-9. URL Return