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Diabetic Gastroparesis—Know the Symptoms and Your Treatment Options

Gastroparesis is a gastrointestinal condition occurring in people with long-term diabetes that gets too little attention. Start by recognizing the symptoms and possible treatments.

with Mahdusudan Grover, MD, and Michael Camilleri, MD

Gastroparesis gets little attention even though it is a relatively common complication arising in many individuals with diabetes—both type 1 diabetes and type 2 diabetes. It’s even more common in individuals with both diabetes and obesity.1

Good blood sugar control and a blenderized diet reduce diabetic gastroparesis symptoms.If you have diabetes, stomach pains, bloating, and nausea may be a sign that you gastroparesis. Photo: 123rf

Common symptoms include feeling full before you can finish your meal and staying full long after the meal is over as well as bloating, nausea, vomiting, abdominal pain, and even nutritional deficiencies.1,2

According to results of one study,3 as many as 29% of patients with these gastric symptoms also have diabetes and may experience nerve problems in their stomach, similar to that of peripheral neuropathy that causes tingling and numbness, even pain, in the extremities. Poor blood sugar control may also be a contributing factor.4

If you have had diabetes for a while, this might explain the abdominal pain and other baffling symptoms you’ve been experiencing after you eat.

Diabetic Gastroparesis Causes Serious Abdominal Discomfort 

It could be that you are one of the estimated 25-55% individuals with type 1 diabetics or the one-in-three people who have type 2 diabetes and experience symptoms of gastroparesis for which there isn’t yet an effective treatment targeted to improve this gastrointestinal condition.3

Let’s gain some perspective on the management of this gastrointestinal condition that’s further complicated by the presence of diabetes. Patients who sought out Mahdusudan Grover, MD, an assistant professor of medicine and a gastroenterologist at the Mayo Clinic in Rochester, Minnesota, hoping to gain relief from gastroparesis had only one option: metoclopramide (Reglan), the only drug approved to help patients with the condition but it comes with serious potential side effects and black box warnings

Calling the situation “dark and bleak”—until now. New treatment options, including surgical and drug options are now becoming available with more therapeutic possibilities on the horizon, says Dr. Grover. Among the expanding therapies is a surgical procedure called G-POEM, or Gastro Peroral Endoscopic Myotomy.

Dr. Grover explains that the procedure involves removing a part of the stomach called the pylorus to help the stomach empty into the intestines more easily. Unfortunately, he says it’s too soon to know which patients may benefit the most by having the operation.

However, there is an endoscopic procedure, called EndoFLIP, which can determine if there is problem with the way the pylorus is working, and by gathering this information, it will narrow the possibility to those patients who clearly have poor pyloric function.

Currently, Dr. Grover estimates that 30 to 40% of patients with gastroparesis have something wrong with the pylorus. While there are no research in the United States available to confirm the prevalence of diabetes gastroparesis, there are several such studies underway in Europe that will begin to inform us of the frequency of this GI condition.

Another limitation to widespread adoption of the G-POEM is that there has been no research yet to compare the surgery to a “sham” procedure, says Michael Camilleri, MD, professor of medicine, pharmacology, and physiology, is also an endocrinologist at the Mayo Clinic in Rochester, which is needed to confirm that the benefits are real.

Still, Dr. Camilleri says that the surgery looks promising and is largely safe, making it an encouraging option for those whose Endo-FLIP examinations show some pyloric dysfunction.

Potential Drugs Offer Relief of Symptoms of Gastroparesis

There are also some medications that have been approved for other uses that doctors are increasingly trying in patients who have gastroparesis, says Dr. Grover. Aprepitant, for example, is approved to treat the nausea and vomiting that commonly arises following cancer chemotherapy.

This medication is one that he often considers prescribing to patients who are experiencing the bloating, abdominal pain and vomiting brought about from diabetic gastroparesis. However, it has had mixed results in reducing nausea.

“I tell my patients that aprepitant hasn’t been approved to treat their condition per se but that I have found it to improve similar symptoms in many other patients,” says Dr. Grover. Another drug, prucalopride, approved for constipation, seems to improve digestion. In the most recent study,5 prucalopride seems to have increased gastric motility, which accelerated gastric emptying. If this is confirmed in larger studies that are underway, this drug will be a game changer—so stay tuned.

Several new drugs are currently under investigation, says Dr. Camilleri, although the chance of approval is still years away. One is called velusetrag, and another is TAK-906. The former works in the same way as prucalopride while the latter may help lessen many of the symptoms of GI distress.

Other drugs include tradipitant, which may help with the stomach’s signaling ability, and relamorelin, which has been shown to improve symptoms like the abdominal pain and the nausea, but it also accelerates stomach emptying, which may not be beneficial.

Patients should ask their doctors about clinical trials to see if you are eligible to participate in those being done for gastroparesis,4 Dr. Grover says. This will give you a chance to receive treatment with one of the investigational drugs.

Managing Diabetes Lessen the Risk of Diabetic Gastroparesis

Many endocrinologists focus patient education to improve diabetic gastroparesis on managing blood sugar levels, says Dr. Camilleri. While there is some evidence that those whose poor glucose management and high hemoglobin A1c levels are more likely to end up in the hospital with gastroparesis, achieving good blood glucose is not a “miracle cure” he says.

Dr. Grover adds that better management of blood glucose may help some patients feel better. You may want to talk to your endocrinologist about using an insulin pump, which will continuously monitor your blood sugar and deliver insulin as needed. By allowing your blood sugar to be automated, you may find that you feel better in many ways, including improvements in the symptoms related to the diabetic gastroparesis.

There are some treatments for diabetes itself that can cause the stomach to empty more slowly, Dr. Camilleri says.  These drugs end in “-tide,” like exenatide (Byetta)—a glucagon-like peptide-1 receptor agonist (GLP-1).

There are other good diabetes medications, such as the dipeptidyl peptidase 4 (DPP-4) inhibitors, or gliptins, but they don’t have as favorable an impact on gastric symptoms. When working with his diabetic patients who have gastroparesis, he makes a specific effort to be sure any medications given for blood sugar management won’t cause or worsen stomach problems.

Dietary Management Is Key to Improving GI Symptoms

For some individuals the easiest method for feeling better—a semi-liquid diet—can be hard to implement, says Dr. Grover. The way to reduce most of the unpleasant symptoms is to blend up solid food into a soft paste, which solves the problem of poor gastric emptying, but this is often unappealing and so not readily embraced.

Dr. Camilleri agrees liquids and blended solid foods are often much better tolerated but his patients find it distasteful. So he’ll often say, “Consider this: blending up a peanut butter sandwich is a better option than tube feeding,” which may happen if the symptoms get bad and last long enough. Often, individuals who are very rigorous with their diet are able to avoid the need for medications altogether,6 the doctors point out.

Many patients–about 80%–can avoid tube feeding by adjusting your diet to facilitate speedy gastric emptying.6 Dr. Camilleri says: “Gastroparesis is a chronic condition that will probably not go away but also isn't likely to get worse.”

Be aware of the potential for nutrient deficiencies of some minerals, like copper and zinc,6 says Dr. Grover. This is more likely to occur when the condition has been present a long time. He also warns against any suggestion that you are a candidate for gastric bypass surgery or removing the stomach as a way to manage the symptoms. “This often replaces one problem with another,” he says.

Patients also need to stay well hydrated, particularly in the summer months or when the weather is warm, Dr. Grover adds. Some patients have symptoms whether they are eating or drinking. If you are having issues drinking, it’s better to have IV fluids than to risk dehydration.

“This condition isn’t transient,” Dr. Grover says. “Having diabetic gastroparesis is a chronic condition just as diabetes likely is, so you will want to learn to manage it for the long-term.”

Neither doctor has any financial conflicts regarding this discussion.

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