Time trends in gastroparesis treatment

[Management of gastroparesis care in Germany - a survey by the working group of guiding gastroenterologic clinicians (Arbeitsgemeinschaft Leitender Gastroenterologischer Krankenhausärzte, ALGK)]

INTRODUCTION

The treatment of gastroparesis can be difficult in everyday clinical practice. The aim of this anonymous survey of members of the Arbeitsgemeinschaft Leitender Gastroenterologischer Krankenhausärzte e.V. (ALGK) was to investigate the management of gastroparesis care in Germany.

MATERIAL AND METHODS

The ALGK conducted a member survey using a standardized anonymous questionnaire including 11 questions from 14.04.2023 to 29.04.2023. The questions covered diagnostic and therapeutic procedures as well as various aspects of the management of gastroparesis.

RESULTS

The response rate was 21.4% (62 members). Only 6.56% of all respondents assessed the prevalence of gastroparesis correctly as estimated by current epidemiological publications. 68.85 % of all respondents used gastric emptying scintigraphy for diagnosis. 51.61% regarded an individualized therapy as the most important treatment goal, taking into account etiology and impact of symptoms, compared to symptomatic treatment of leading clinical symptom in 43,55 %. First choice treatment was medical treatment in 41.94%, dietary recommendations in 27.42% and endoscopic interventions in 24.2%. 100% of respondents used prokinetics, 40.32% used antiemetics while only 4.84% used analgesics. Insufficient availability of medical treatment options represents a need of action for 85.48%, compared to lacking official approval of available drugs for this indication for 48,39% of all respondents. Treatment options with little evidence were used quite frequently (e.g. use of herbal therapies in 43.55%).

DISCUSSION

Overall, the frequency of gastroparesis was underestimated in the current survey. Endoscopic options are quite often used as first-line treatment. Although symptom-guided treatment is important for the majority of respondents, prokinetics are predominantly used.

Diabetic Gastroparesis and its Emerging Therapeutic Options: A Narrative Review of the Literature

Diabetic gastroparesis (DG) is one of the many complications of diabetes mellitus (DM). Even though this condition surfaces years after uncontrolled disease, it affects the quality of life in several ways and causes significant morbidity. Common symptoms experienced by the patients include postprandial nausea, vomiting, abdominal fullness, and pain. Strict glycemic control is essential to evade the effects of DG. The purpose of this review article is to briefly study the pathophysiology, clinical features, diagnostic modalities, and the effects of DG on different aspects of life. Furthermore, it also focuses on the emerging treatment modalities for DG. Tradipitant and relamorelin are two such treatment options that are gaining noteworthy recognition and are discussed in detail in this review article. As observed through various clinical trials, these drugs help alleviate symptoms like nausea, vomiting, abdominal pain, and bloating in patients suffering from DG, thereby targeting the most common and bothersome symptoms of the disease. This leads to an improvement in the quality of life, making it a reliable treatment option for this disease. But while pharmacological intervention is vital, psychological support and lifestyle changes are equally important and are the reason why a multidisciplinary approach is required for the treatment of DG.

Standard Adult Gastric Emptying Scintigraphy Criteria Is Applicable for Partial Meal Ingestion

BACKGROUND/AIMS

Gastric emptying scintigraphy is commonly performed to assess for dysmotility. A standardized meal with associated threshold criteria was established in 2000 to enable robust interpretation. However, no guidance is available to interpret results when patients do not ingest the entire meal. The purpose of this study is to determine the continued appropriateness of the threshold criteria in contemporary clinical practice and its relevance for partially ingested meals.

METHODS

This retrospective study analyzed patients (n = 1365 total) who underwent solid-phase gastric emptying scintigraphy at an academic medical center. Patients were stratified based on their completion of the standard meal. Patients were further stratified into normal and delayed gastric emptying cohorts based on the current criteria. Percent gastric retention values at 1, 2, 3, and 4 h were compared.

RESULTS

Median (95% upper reference) normal gastric retention values for the complete standard meal were 64% (87%) at 1 h, 25% (60%) at 2 h, 13% (54%) at 3 h and 4% (9%) at 4 h. Consumption of at least 50% of the standard meal yielded similar retention; 53% (86%) at 1 h, 19% (58%) at 2 h, 6% (29%) at 3 h and 3% (10%) at 4 h. There was no significant age- or gender-specific differences using the current criteria, and no differences were observed based on diabetic status. Retention values matched well with the current criteria and validated with data-driven clustering.

CONCLUSION

Adult normative standards for gastric emptying scintigraphy are appropriate for differentiating normal and delayed populations and can be applied to partial meals with at least 50% completion.

Auricular vagal nerve stimulation enhances gastrointestinal motility and improves interstitial cells of Cajal in rats treated with loperamide

BACKGROUND

Gastrointestinal (GI) motility disorders affect a large proportion of the population with limited treatment options. The aims of this study were to investigate the potential of a non-invasive method of auricular vagal nerve stimulation (aVNS) for treating GI dysmotility and to explore possible mechanisms involving slow waves and interstitial cells of Cajal (ICC).

METHODS

Normal rats were treated daily with loperamide for 1 week and then treated, while still on daily loperamide, with aVNS/Sham-aVNS for another 1 week. Gastric emptying (GE), small intestine transit (SIT), and GI slow waves were measured. The plasma level of pancreatic polypeptide (PP) and noradrenaline (NE) was assessed by ELISA. ICC in the gastric antrum were detected by immunohistochemistry.

KEY RESULTS

(a) aVNS significantly increased the percentage of normal GI slow waves (p < 0.05 for both fasting and postprandial states, vs. Sham-aVNS) and accelerated GE (p < 0.05, vs. Sham-aVNS) and SIT (p < 0.05, vs. Sham-aVNS) impaired by loperamide. (b) aVNS increased plasma PP (p < 0.01) and decreased plasma NE (p < 0.01), compared with Sham-aVNS. (c) Gastric ICC was decreased by loperamide (p < 0.01) but increased after aVNS (p < 0.01, vs. Sham aVNS).

CONCLUSIONS & INFERENCES

Loperamide induces upper GI dysmotility. aVNS accelerates upper GI transit and improving pace-making activity mediated via the ICC. Non-invasive aVNS may have a therapeutic potential for upper GI dysmotility.

[Endoscopic tunneling procedures in achalasia and gastroparesis]

Since the first publication of peroral endoscopic myotomy (POEM) by Haruhiro Inoue et al. in 2008 in Japan, various novel endoscopic procedures have been established, which are performed after iatrogenic creation of a submucosal tunnel as a "new space" 1. Through the artificially formed access in the tela submucosa, interventions in the muscular layer of the esophagus and stomach can be performed while carefully sparing the mucosal layer 2. These include, peroral myotomy of the esophageal muscle layer in patients with achalasia (POEM) and myotomy of the pylorus in patients with gastroparesis (antropyloromyotomy, G-POEM). Further indications include splitting of Zenker diverticulum in POEM technique ("Z-POEM") as well as the removal of subepithelial tumors (STER: submucosal tunneling, endoscopic resection). The long-term therapeutic success (with > 80 % response) of these innovative procedures has now been proven by controlled studies, especially in achalasia 2 3 4 5 6.

Time Trends in Healthcare Utilization Due to Self-Reported Functional Diseases of the Stomach

INTRODUCTION

Cohort studies from referral centers suggest an increasing burden of functional gastric disorders, with frequent emergency room (ER) visits, hospitalizations, or absenteeism. We hypothesized that recruitment from tertiary care sites skews results and thus investigated the burden of these illnesses, using the population-based data of the Medical Expenditure Panel Survey (MEPS).

METHODS

Using MEPS data for the years 2000-2015, demographic, economic, healthcare-related, and quality-of-life indicators were extracted for adults reporting the diagnosis of functional gastric diseases to assess trends and to compare results with data from all adults surveyed.

RESULTS

Between 2000 and 2015, 2.7 ± 0.2% of the adults surveyed reported a functional gastric illness. Within the period studied, 28.8 ± 2.8% and 17.9 ± 1.6% of this cohort reported ER visits or hospitalizations, respectively. Only a fraction of these persons attributed the ER visits (22.6 ± 0.9%) or admissions (10.9 ± 0.8%) to the functional gastric disorder. Rates remained stable rates during the period studied. Female sex, measures of physical function, comorbidities, and an income below the poverty line were predictors of healthcare utilization. While utilization was stable over time, annual costs increased by 113.9 ± 16.6% during the study period, outpacing the inflation rate of 37.6%.

CONCLUSIONS

Persons with functional gastric disorders have significant healthcare needs and face increasing costs of care, largely due to coexisting illnesses. While it is important to recognize this impact, the need for emergency care or hospitalizations remained stable and lower than reported for patients seen in tertiary referral centers, providing reassuring information for patients and providers.

The impact of risk factors on gastroparesis at an urban medical center

Background

Gastroparesis is a complex and poorly understood disease. The literature is lacking with respect to the epidemiology of patient comorbidities and their effect on gastric emptying. We aimed to describe the most common comorbid conditions among patients with gastroparesis in an urban population and quantify the effect of these comorbidities on the severity of delayed gastric emptying (DGE).

Methods

We examined the medical records of all patients diagnosed with gastroparesis at a quaternary care center between 2014 and 2015. The severity of DGE was analyzed after patients were stratified for possible causative etiologies. Likelihood ratio tests were used to assess the significance of demographic and scintigraphic variation in this population.

Results

Of the 221 patients, 56.1% were Caucasian and 31.7% were African American. Among these patients, 29.4% had evidence of medication-associated gastroparesis, 29.0% had diabetes-associated gastroparesis, and 31.7% had idiopathic disease. African American patients with gastroparesis were more likely to have diabetic gastroparesis than patients of other races (P=0.01). There was a statistically significant relationship between the number of major risk factors and the severity of a patient's DGE (P=0.004).

Conclusions

Among a diverse urban population, patients with DGE often carry multiple comorbid conditions that serve as risk factors for the development of gastroparesis, including prescriptions for narcotic medications. Greater numbers of these comorbid conditions are associated with more severe disease. Demographics are significantly associated with the etiology and severity of gastroparesis; in particular, African American patients are more likely to have diabetic gastroparesis than patients of other races.

Diabetic Gastroparesis

This review covers the epidemiology, pathophysiology, clinical features, diagnosis, and management of diabetic gastroparesis, and more broadly diabetic gastroenteropathy, which encompasses all the gastrointestinal manifestations of diabetes mellitus. Up to 50% of patients with type 1 and type 2 DM and suboptimal glycemic control have delayed gastric emptying (GE), which can be documented with scintigraphy, 13C breath tests, or a wireless motility capsule; the remainder have normal or rapid GE. Many patients with delayed GE are asymptomatic; others have dyspepsia (i.e., mild to moderate indigestion, with or without a mild delay in GE) or gastroparesis, which is a syndrome characterized by moderate to severe upper gastrointestinal symptoms and delayed GE that suggest, but are not accompanied by, gastric outlet obstruction. Gastroparesis can markedly impair quality of life, and up to 50% of patients have significant anxiety and/or depression. Often the distinction between dyspepsia and gastroparesis is based on clinical judgement rather than established criteria. Hyperglycemia, autonomic neuropathy, and enteric neuromuscular inflammation and injury are implicated in the pathogenesis of delayed GE. Alternatively, there are limited data to suggest that delayed GE may affect glycemic control. The management of diabetic gastroparesis is guided by the severity of symptoms, the magnitude of delayed GE, and the nutritional status. Initial options include dietary modifications, supplemental oral nutrition, and antiemetic and prokinetic medications. Patients with more severe symptoms may require a venting gastrostomy or jejunostomy and/or gastric electrical stimulation. Promising newer therapeutic approaches include ghrelin receptor agonists and selective 5-hydroxytryptamine receptor agonists.

From Harmful Treatment to Secondary Gain: Adverse Event Reporting in Dyspepsia and Gastroparesis

INTRODUCTION

Medical management of gastroparesis and functional dyspepsia remains difficult with several recent trials showing limited or no benefit. If treatment comes with only marginal improvements, concerns about adverse events become more relevant. We therefore examined the type and outcomes of side effects submitted to a public repository.

METHODS

We searched the Federal Adverse Event Reporting System for reports associated with the treatment of dyspepsia or gastroparesis. Demographic data, medications used and implicated, side effects, and outcomes were abstracted for the years 2004-2015.

RESULTS

Acid-suppressive agents and prokinetics were the most commonly listed medications with a stronger emphasis on prokinetics in gastroparesis. Submissions related to metoclopramide by far exceeded reports about other agents and mostly described tardive dyskinesia or other neurological concerns. They peaked around 2012, driven by submissions through legal workers. Most reports about metoclopramide described short-term use to prevent or treat nausea and vomiting. Concerns about acid-suppressive medications increased over time and spanned a wide spectrum of potential problems, including osteoporosis, worsening renal function, or cardiac events.

CONCLUSION

Despite biasing factors, such as pending legal action, the voluntary repository of adverse events provides insight into current medical practice and its associated risk. Knowing about common and uncommon, but potentially serious risks may enable patients and providers to decide on effective and safe management strategies.

Emerging strategies for the treatment of gastroparesis

Gastroparesis is a syndrome of delayed gastric emptying in the absence of mechanical obstruction. Symptoms can be debilitating, affect nutritional states, and significantly impact patients' quality of life. The management of these patients can prove quite difficult to many providers. This article will review the current management recommendations of gastroparesis, discuss investigational medications and interventions, and summarize future directions of therapies targeting the underlying disease process. Current therapies are subdivided into those improving gastric motility and those directly targeting symptoms. Non-pharmacologic interventions, including gastric stimulator implantation and intra-pyloric botulinum toxic injection are reviewed. A discussion of expert opinion in the field, a look into the future of gastroparesis management, and a key point summary conclude the article.

Empirically Supported Use of Psychiatric Medications in Adolescents and Adults with IBD

BACKGROUND

The use of psychotropic medications, particularly antidepressants, is common in patients with inflammatory bowel disease (IBD) in spite of a lack of their robust efficacy in this population. This review provides an overview of the use trends of different classes of antidepressant and anti-anxiety medication and their effects on mood, nervous system function, gastrointestinal physiology and immunity drawing from the literature available in the general population, other medical conditions, and when available, patients with IBD. It also covers the evidence base for the actions, efficacy, and potential complications of antidepressants organized by different classes.

METHODS

We conducted a PubMed search of articles relating the different drug classes probed to the terms above in different populations of interest. All types of articles were accepted including case reports and series, open and randomized trials, reviews, and expert opinion. We also examined the reference lists of the publications found.

RESULTS

Selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs) are the most commonly prescribed agents for anxiety and depression in patients with IBD, though their efficacy for these conditions in the general population are mild to moderate at best. SSRIs are generally well tolerated, though at higher doses, they, like most antidepressant classes, can be associated with activation, serotonergic syndrome, and increased suicidal ideation. TCAs have many more serious side effects but have some shown efficacy for functional GI symptoms. A newer class, the serotonin noradrenergic reuptake inhibitors (SNRIs), can be effective for refractory depression, anxiety and chronic pain syndromes with a side effect profile similar to both SSRIs and more mild manifestations of TCAs. Mirtazapine has moderate efficacy for depression if sedation and weight gain side effects are tolerated and some small support for use in nausea and vomiting. Bupropion targets dopamine and noradrenaline reuptake and has moderate efficacy for depression, and some small support for use in fatigue and smoking cessation. Buspirone has an indication for generalized anxiety disorder though studies show only a minimal benefit. It has some growing evidence for use in functional dyspepsia. Most of these agents have physiological effects on the brain, immune system, and gastrointestinal tract (with the exception of bupropion) hence their therapeutic and side effects manifested in these systems.

CONCLUSION

Antidepressant medications are frequently prescribed for depression, anxiety disorders, and chronic pain syndromes, but overall support for their efficacy is modest at best. Psychological interventions have growing support for having much more robust effects without the side effects of antidepressants and should be considered first-line treatment or at least an adjunct to psychotropic medications for these conditions.

Diabetic gastroparesis alters the biomagnetic signature of the gastric slow wave

BACKGROUND

Gastroparesis is characterized by delayed gastric emptying without mechanical obstruction, but remains difficult to diagnose and distinguish from other gastrointestinal (GI) disorders. Gastroparesis affects the gastric slow wave, but non-invasive assessment has been limited to the electrogastrogram (EGG), which reliably characterizes temporal dynamics but does not provide spatial information.

METHODS

We measured gastric slow wave parameters from the EGG and magnetogastrogram (MGG) in patients with gastroparesis and in healthy controls. In addition to dominant frequency (DF) and percentage power distribution (PPD), we measured the propagation velocity from MGG spatiotemporal patterns and the percentage of slow wave coupling (%SWC) from EGG.

KEY RESULTS

No significant difference in DF was found between patients and controls. Gastroparesis patients had lower percentages of normogastric frequencies (60 ± 6% vs 78 ± 4%, p < 0.05), and higher brady (9 ± 2% vs 2 ± 1%, p < 0.05) and tachygastric (31 ± 2% vs 19 ± 1%, p < 0.05) frequency content postprandial, indicative of uncoupling. Propagation patterns were substantially different in patients and longitudinal propagation velocity was retrograde at 4.3 ± 2.9 mm/s vs anterograde at 7.4 ± 1.0 mm/s for controls (p < 0.01). No difference was found in %SWC from EGG.

CONCLUSIONS & INFERENCES

Gastric slow wave parameters obtained from MGG recordings distinguish gastroparesis patients from controls. Assessment of slow wave propagation may prove critical to characterization of underlying disease processes. Future studies should determine pathologic indicators from MGG associated with other functional gastric disorders, and whether multichannel EGG with appropriate signal processing also reveals pathology.

Systematic review and meta-analysis: Gastric electrical stimulation for gastroparesis

BACKGROUND

Controlled trials of gastric electrical stimulation (GES) for gastroparesis reported no significant improvement in symptoms, while open label studies suggested substantial clinical benefits.

AIM

To determine if GES is effective in reducing symptoms in patients with gastroparesis.

METHODS

We searched PubMed and Embase for articles published in English (1990-2014) using "gastroparesis" as a search term restricted to "clinical trial". We included studies describing repeated patient-based symptom ratings before and during standardized treatments of at least one week duration.

RESULTS

Five studies randomly allocated patients to periods with or without GES. Total symptom severity (TSS) scores did not differ between these periods (0.17 [95% confidence interval: -0.06 to 0.4]; P=0.15). However, sixteen open label studies of GES showed a significant TSS decrease (2.68 [2.04-3.32]; Q=39.0; P<0.001). Other treatment modalities similarly improved TSS by 1.97 [1.5-2.44] for medical therapy (MED), by 1.52 [0.9-2.15] for placebo arms (PLA), and by 2.32 [1.56-3.06] for botulinum toxin (BTx). There were significant differences in baseline TSS ratings among these studies (GES: 6.28 [6.28-7.42]; MED: 4.76 [4.09-5.42]; PLA: 4.59 [3.77-5.42]; BTx: 6.02 [5.3-6.74]; Q=35.1; P<0.001). Meta-regression analysis showed these baseline differences to significantly impact TSS ratings during treatment (Q=71.8; P<0.001).

CONCLUSION

Independent of the treatment modality, baseline symptom severity impacts treatment results in gastroparesis. Considering the skewed population with refractory symptoms, regression to the mean likely contributes to the substantial discrepancies between the reported results of controlled and open label GES studies, raising questions about the use of GES outside of defined clinical trials.

Gastroparesis in children

PURPOSE OF REVIEW

Gastroparesis is a disorder with delayed gastric emptying in the absence of mechanical obstruction. It is one of the more common dysmotilities that occur in the gastrointestinal tract, and is thought to primarily affect adults. Pediatric cases of gastroparesis were considered rare; however, recent evidence suggests growing recognition in children and adolescents. Therefore, it is important for the pediatric caregiver to understand the condition and the treatment options available.

RECENT FINDINGS

The majority of patients are women, and presentation is usually with symptoms of persistent nausea, emesis, postprandial pain and bloating, and early satiety. Weight loss may occur in some cases, though this is not universal. The majority of cases are idiopathic, with diabetes mellitus the second most common cause.

SUMMARY

Treatment consists of symptomatic relief with medication to counteract the nausea, emesis, pain, bloating, gastroesophageal reflux, early satiety, and improve gastric emptying. Dietary modification is also used with small meals and avoidance of high fiber and fat-containing foods. Recalcitrant cases of gastroparesis require the use of additional approaches such as jejunal feeds, intrapyloric botulinum toxin, gastric emptying procedures such as pyloroplasty, and gastric electrical stimulation. We will review these options in this article.