Gastroparesis When Second-Line Pharmacotherapy Has Not Worked

This protocol addresses gastroparesis that remains inadequately controlled after a trial of second-line pharmacologic agents — where nausea, vomiting, early satiety, and postprandial fullness persist despite medical management.

Prior treatment failure

Second-line agents did not achieve adequate symptom control Agents from the second-line pharmacologic group — including domperidone, prucalopride, aprepitant, nortriptyline, buspirone, or cannabidiol — failed to deliver sufficient improvement in nausea, vomiting, early satiety, and postprandial fullness at 4–8 weeks of treatment.

Next step

When pharmacologic management has not controlled symptoms, the approach shifts to procedural interventions — the full structured protocol defines which options apply and under what conditions.

Treatment goal

✓ Improvement in nausea and vomiting.

Instant Access to Structured Evidence-Based Regimens

References

DOI: 10.1053/j.gastro.2025.08.004

In patients with gastroparesis refractory to medical management, the AGA suggests against the routine use of botulinum toxin injection (BTI).

Prior studies have used doses of both 100 units and 200 units, both of which are supported by the experts on the panel.

In patients with gastroparesis refractory to medical therapy, the AGA suggests against the routine use of G-POEM.

In patients with gastroparesis refractory to medical therapy, the AGA makes no recommendation regarding the use of surgical pyloric interventions (pyloromyotomy or pyloroplasty).

In patients with gastroparesis refractory to medical therapy, the AGA suggests against the routine use of GES.

When used, patients should be informed that GES aims to primarily improve nausea and vomiting, not abdominal pain.

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