3.3.4.0 Gas­tro­pare­sis

Treat­ment for di­a­bet­ic gas­tro­pare­sis may be very chal­leng­ing. A low-fiber, low-‍fat eat­ing plan pro­vided in small fre­quent meals with a greater propor­tion of liq­uid calo­ries may be use­ful (136-138). In ad­di­tion, foods with small par­ti­cle size may im­prove key symp­toms (139). With­draw­ing drugs with ad­verse ef­fects on gas­troin­testi­nal motil­i­ty in­clud­ing opi­oids, an­ti­cholin­er­gics, tri­cyclic an­tide­pres­sants, GLP-1 RA, pram­lin­tide, and pos­si­bly dipep­tidyl pep­ti­dase 4 in­hibitors may also im­prove in­testi­nal motil­i­ty (136,140). In cases of se­vere gas­tro­pare­sis, phar­ma­co­log­ic in­ter­ven­tions are need­ed. Only meto­clo­pramide, a proki­net­ic agent, is ap­proved by the FDA for the treat­ment of gas­tro­pare­sis. How­ev­er, the level of ev­i­dence re­gard­ing the benefits of meto­clo­pramide for the man­age­ment of gas­tro­pare­sis is weak, and given the risk for se­ri­ous ad­verse ef­fects (ex­trapyra­mi­dal signs such as acute dys­ton­ic re­ac­tions, drug-‍in­duced parkin­son­ism, akathisia, and tar­dive dysk­i­ne­sia), its use in the treat­ment of gas­tro­pare­sis be­yond 12 weeks is no longer rec­om­mend­ed by the FDA or the Eu­ro­pean Medicines Agen­cy. It should be re­served for se­vere cases that are un­re­spon­sive to other ther­a­pies (140). Other treat­ment op­tions in­clude dom­peri­done (avail­able out­side of the U.S.) and ery­thromycin, which is only ef­fective for short-‍term use due to tachy­phy­lax­is (141,142). Gas­tric elec­tri­cal stim­u­la­tion using a sur­gi­cal­ly im­plantable de­vice has re­ceived ap­proval from the FDA, al­though its efficacy is vari­able and use is lim­it­ed to pa­tients with se­vere symp­toms that are re­frac­to­ry to other treat­ments (143).