AGA Clinical Practice Guideline on Management of Gastroparesis

Background & Aims: Gastroparesis is a complex gastric motility disorder characterized by nausea, vomiting, and other symptoms associated with a delay in gastric emptying in the absence of mechanical obstruction. Variations in diagnostic testing and limited effective treatments make caring for this patient population challenging. The American Gastroenterological Association developed this guideline to provide recommendations for ensuring an accurate diagnosis and identifying evidence-based, effective treatments among the available pharmacologic and procedural interventions for patients with idiopathic gastroparesis or gastroparesis related to diabetes. Methods: The Grading of Recommendations Assessment, Development and Evaluation framework was used to assess evidence and develop this guideline. The Guideline Panel prioritized clinical questions and outcomes, conducted an evidence review, and used the Evidence to Decision Framework to develop recommendations. Results: The Guideline Panel agreed on 12 recommendations. A conditional recommendation was issued against using 2-hour gastric emptying testing and in favor of 4-hour testing in patients with suspected gastroparesis. There are conditional recommendations for the use of metoclopramide and erythromycin in patients with gastroparesis. Conditional recommendations were issued against the use of domperidone, prucalopride, aprepitant, nortriptyline, buspirone, and cannabidiol as first-line therapies. In addition, conditional recommendations were issued against the routine initial use of gastric per-oral endoscopic pyloromyotomy or gastric electrical stimulation in patients with gastroparesis, reserving these treatments for select patients with symptoms refractory to medical therapies. No recommendation was given regarding the use of surgical pyloromyotomy and surgical pyloroplasty, which were identified as procedures with knowledge gaps in their use for treatment for gastroparesis. Conclusions: The diagnosis of gastroparesis requires the use of 4-hour gastric emptying tests. Metoclopramide or erythromycin is appropriate for initial pharmacologic treatment. Other treatment recommendations require shared patient-physician decision making. There are still considerable unmet needs in the treatment of gastroparesis.