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Medical management of gastroparesis

Prokinetics, antiemetics and antacids — what each does, what to expect, and why medications often stop working over time.

Most patients arriving at Vanguard have already tried medication. Many were never told why it worked for a while and then stopped, or why a drug that helps one patient does nothing for another.

Vanguard manages gastroparesis medically as well as surgically. That matters: a practice that only operates will steer you toward the operating room. Here, medication is a real option, not a formality on the way to surgery.

Most patients here are managed medically first — surgery is what happens when medication has genuinely been given its chance.

Taylor Rich, APRN, sees many of these patients in clinic. Dr. Hughes brought her on so that appointments would be easier to get, and he trained her in this work himself. The two of them decide the plan together, and Dr. Hughes is available to see you at any point.

Three classes of medication

There are three groups of drugs used in gastroparesis, and they do different jobs. Only one of them treats the underlying motility problem.

Prokinetics - the ones that treat gastroparesis

Prokinetics promote movement. These are the actual gastroparesis drugs, and they’re recommended first line.

Metoclopramide (Reglan oral tablets and Gimoti nasal spray) is usually the first choice. It’s inexpensive, easy to obtain, and works well for a lot of people.

Three things to know about metoclopramide, and these apply to every form of it — Reglan tablets and Gimoti nasal spray alike:

  • It has a significant number of drug interactions. It cannot be given with bupropion (Wellbutrin), fluoxetine (Prozac), or paroxetine (Paxil).
  • It carries a boxed warning for tardive dyskinesia — involuntary muscle movements, often of the face, such as lip smacking. Only a small percentage of patients develop it, but every patient prescribed metoclopramide should hear about it.
  • It is not intended for continuous long-term use. Per the FDA label, treatment should not exceed 12 weeks.

On the FDA label: metoclopramide is approved specifically for diabetic gastroparesis. That’s true of Reglan and Gimoti equally. It is routinely and appropriately prescribed for non-diabetic gastroparesis — this is ordinary, well-established practice — but if you read the packaging and see “diabetic gastroparesis,” that’s why.

Gimoti® is metoclopramide delivered as a nasal spray, and Vanguard often prefers it. The reason is straightforward: a gastroparetic stomach is unreliable about when it digests and empties, which makes absorption of a swallowed pill unpredictable. A nasal spray bypasses the stomach entirely and is delivered on the same timeline every dose.

Unlike the oral forms of metoclopramide, which are absorbed unpredictably, Gimoti works in 1-2 minutes. This allows patients to use it as needed, rather than on a scheduled basis. Because it isn’t taken on a fixed daily schedule, total exposure over a course of treatment is lower, and patients tend to have fewer side effects. In practice this has been a meaningful advance.

How long any course of metoclopramide should run is a decision for you and your prescriber, within the FDA labeling above.

Evoke Pharma runs a copay program that brings cost to $0 or $20 for eligible patients — though not for anyone on Medicare or Medicaid.

Full prescribing information and medication guide: gimotirx.com

Erythromycin is a macrolide antibiotic that’s rarely used as an antibiotic anymore — there are better options — but at lower doses it also can work as a prokinetic. The chemical structure is similar to motilin, a hormone produced by the body to help the stomach empty. It is taken three times per day, not as needed. It must be taken by mouth, and therefore is less predictable and less effective than Gimoti nasal spray. It also requires checking EKGs on a regular basis to assess for QT prolongation, particularly when given with ondansetron. Vanguard typically uses this for those that cannot take or tolerate Gimoti nasal spray.

Domperidone is a prokinetic obtained from outside the US, so it is not approved or regulated by the FDA. There are considerable hoops involved, and availability has been a problem. Vanguard does not prescribe it, consistent with US guidelines. Some patients have taken it previously.

Important — why your medication stopped working: All of these are associated with tachyphylaxis, which simply means they lose effect over time. It might be a couple of months, it might be a couple of years. Patients often assume their disease has worsened or that they did something wrong. Usually neither is true — the drug just stopped working, which is a known property of the drug.

Prucalopride (Motegrity) is a prokinetic for the colon that can also work as a prokinetic for the stomach. Many patients who can’t take a stomach prokinetic find it helps both the gastroparesis and the constipation. Taken by mouth once a day, with few side effects.

Antiemetics — the ones that treat nausea

Antiemetics manage nausea and vomiting. They treat the symptom, not the problem.

  • Promethazine (Phenergan) and ondansetron (Zofran) — the two most patients have already tried. Ondansetron comes in a form that dissolves under the tongue
  • Prochlorperazine (Compazine) — older, same class as Phenergan
  • Scopolamine patch — absorbed through the skin, often prescribed alongside the others. Particularly useful in gastroparesis precisely because it doesn’t have to be swallowed

One pairing to know about — ondansetron and erythromycin: Both can prolong the QT interval, a measure of the heart’s electrical timing, and taken together the effect adds up. Many gastroparesis patients end up on exactly this combination: erythromycin for motility, ondansetron for nausea. That is not a reason to avoid either drug — it is a reason to be monitored. If you are on both, expect periodic EKGs. If you are already taking ondansetron and erythromycin is being considered, say so.

Antacids — the ones that treat reflux

Acid reflux and heartburn aren’t technically part of gastroparesis, but they should be. Your stomach makes nearly a gallon of acid a day. If it can’t move downward, it goes up — into the esophagus, which runs behind the heart. That’s the burning and the chest pain.

Most Vanguard patients are on a proton pump inhibitor such as omeprazole (Prilosec), or an H2 blocker such as famotidine (Pepcid). These treat symptoms complicated by gastroparesis, not gastroparesis itself.

One caveat worth raising with your provider: long-term PPI use has been linked to osteoporosis, though the data has become less convincing. Where it’s possible to wean off, that’s generally worth doing. Taylor and Dr. Hughes wean patients off these medications as gastric emptying normalizes and heartburn improves.

Constipation and bowel symptoms

Most gastroparesis patients alternate between diarrhea and constipation. The reason isn’t fully understood, but when stomach emptying improves, these symptoms usually improve too.

Vanguard commonly prescribes for constipation and IBS. Prucalopride (Motegrity) is the preferred agent for gastroparesis patients with constipation, though insurers often require documented failure of first, second, and third-line agents before approving it. Gastroparesis patients often do not tolerate secretagogues — linaclotide (Linzess), lubiprostone (Amitiza), and plecanatide (Trulance) — because they flush liquid into the colon and cause diarrhea.

When medication isn’t enough

Medication is given a genuine trial. When symptoms persist despite dietary modification and an adequate medication trial — or when medication can’t be used because of drug interactions or other conditions — the question becomes a different one:

Is your stomach under pressure?

If you have bloating, fullness, and upper abdominal pain alongside the nausea, your stomach is building up under pressure, and the answer is to decompress it. That’s pyloroplasty.

If it’s nausea and vomiting without the bloating and fullness, it isn’t a pressure problem. That’s gastric stimulation.

That distinction is made on symptoms, not on a test — and it’s a conversation. You make the decision about what is right for you. Are your symptoms severe enough to justify surgery? Both surgeries are outpatient (home same day), laparoscopic procedures with low-risk. However, they are still surgeries. Only you know what the right decision is.

Getting your medication approved

Most gastroparesis patients have a story about insurance. A medication that worked, denied on renewal. Weeks of phone calls. A prescription that sat at a pharmacy while symptoms continued.

Vanguard uses Forus to handle prior authorizations. Forus is not a pharmacy. When Taylor or Dr. Hughes prescribe a medication that will require prior authorization, they send it to Forus. Forus then submits the prior authorization request electronically to your insurance rather than adding it to a stack of paperwork. If it’s denied, Forus files an appeal. If this is denied and there’s a patient assistance program you qualify for, Forus submits the application for you. You receive updates directly from Forus, and you can call or text them directly with any questions.

Forus is free to you. It costs patients nothing, and it costs the practice nothing.

The point of both is the same: the obstacle between you and a medication that works should be our problem to solve, not yours.

This page describes how gastroparesis is treated medically in general terms. It is not medical advice and it is not a substitute for an evaluation. Which medication is right for you, at what dose, and for how long depends on your other conditions and everything else you take — those decisions get made in clinic. Do not start, stop, or change a prescription based on what you read here.

Start with the seminar. Decide afterwards.

One hour, online, free, and it commits you to nothing. You do not need to live in Kentucky or Indiana.

Questions? Call (502) 912-8300, Monday–Friday 8:00 am – 4:00 pm ET.