Gastroparesis Not Controlled by Pharmacologic Therapy: Next-Line Management

Clinical Scenario

This protocol applies to patients with gastroparesis who have undergone standard pharmacologic treatment but have not achieved adequate improvement in gastric emptying or meaningful symptom relief. When drug-based approaches are insufficient, a defined next-line strategy is indicated.

Previous Treatment — Goals Not Reached

First-line pharmacologic management was attempted, which may have included:

Metoclopramide (oral or nasal spray)
Domperidone (where approved)
5-HT4 agonists (prucalopride, felcisetrag, velusetrag)
Motilin agonists (erythromycin, clarithromycin, azithromycin), used short term
Antiemetic agents for symptom control

Despite this approach, the goals of improved gastric emptying and reduced gastroparesis symptoms were not reached — establishing the basis for escalation to this protocol.

Treatment Goals at This Stage

The clinical targets are decreased vomiting frequency and meaningful, sustained control of gastroparesis symptoms.

Approach (Partial Overview)

Management at this stage centres on a device-based intervention carrying FDA humanitarian use device designation, specifically for patients with medically refractory gastroparesis. The full structured regimen — including eligibility criteria, procedural details, and the complete clinical algorithm — is available via the protocol below.

Instant Access to Structured Evidence-Based Regimens

References

DOI: 10.14309/ajg.0000000000001874

Gastric electric stimulation (GES) may be considered for control of GP symptoms as a humanitarian use device (HUD) (conditional recommendation, low quality of evidence).

GES is approved as an HUD, as defined by the FDA for medically refractory DG or IG.

A recent randomized, crossover trial of ON vs OFF GES in patients with medically refractory vomiting with or without delayed GE, GES decreased the vomiting frequency.

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