by Jessica Pyhtila, PharmD, BCPS, BCGP
Diabetic gastroparesis is a common, yet infrequently discussed, complication of diabetes. This condition is a type of nerve damage directly impacting the stomach and, therefore, digestion. Wide swings in blood sugar as well as malnutrition can result from diabetic gastroparesis if left untreated. For this reason, it is important for those with diabetes to be familiar with the symptoms of this condition so it can be caught and treated as early as possible.
What is Diabetic Gastroparesis?
Diabetic gastroparesis refers to a condition where the stomach does not empty into the intestines as quickly as it should. It is a type of neuropathy, or nerve damage, from longstanding uncontrolled diabetes. Nerves in the gastrointestinal tract are fragile and can easily be damaged by changes to the body that occur in diabetes, like high blood sugar.
Under normal circumstances, stomach emptying is a complex and coordinated process in the body. Neurotransmitters like acetylcholine are released by nerves to trigger digestion. The muscles in the stomach then coordinate to churn and release contents into the intestines, regulated by a natural pacemaker in the stomach known as the interstitial cells of Cajal.
In diabetic gastroparesis, this intricate process of digestion is interrupted at several levels. These include:
· Direct damage to the stomach’s nerves, causing the stomach to empty more slowly
· Lower levels of an enzyme called nitric oxide synthase, which is involved with helping movement in the gastrointestinal tract
· Changes in immune system cells, causing damage to the muscle of the stomach as well as the interstitial cells of Cajal which coordinate stomach contractions
· Direct damage to the interstitial cells of Cajal, disturbing the churning rhythm of the stomach
· Direct damage to the stomach’s muscles, interfering with digestion
Risk Factors for Diabetic Gastroparesis
Diabetic gastroparesis is a common complication of diabetes. Between 20 and 50% of people with diabetes have diabetic gastroparesis. It can occur in both Type 1 and Type 2 diabetes. However, it is more common in Type 1 diabetes, impacting up to 65% of those with the Type 1 form of the disease and up to 30% of those with the Type 2 form.
Risk factors for diabetic gastroparesis include:
· Having other diabetes complications, like eye damage, kidney damage, and other forms of nerve damage
· Poor blood sugar control
· Older age
· A longer period of time since your diabetes diagnosis
Although some studies have indicated that women may be at a higher risk of diabetic gastroparesis than men, other studies have found no difference. However, studies have shown that the stomach in women with diabetes empties slower than in men, even in people without diabetic gastroparesis.
Symptoms of Diabetic Gastroparesis
Many people are diagnosed after they start noticing symptoms of diabetic gastroparesis. These include:
· Feeling excessively full after eating, even if you have not eaten much
· Feeling bloated
· Nausea and vomiting
· Appetite loss
· Weight loss
· Abdominal pain
· Wide swings in blood sugar
· Unpredictable responses to mealtime insulin
Of these, nausea is the most common symptom, impacting about 92% of people with diabetic gastroparesis. Vomiting is the second most common symptom, affecting about 84% of people. Feeling bloated is also common, occurring in around 75% of people with the condition. Further, around 60% of people with diabetic gastroparesis feel full, even if they have not eaten very much.
Diabetic gastroparesis can lead to problems such as:
· Poor blood sugar control
· Poor nutrition
· Frequent hospitalizations
· Poor quality of life
Diabetic Gastroparesis Diagnosis
It can be challenging for a doctor to make a diabetic gastroparesis diagnosis. Many times, the condition is not diagnosed until it is advanced and hard to treat. This is because it is difficult to identify diabetic gastroparesis until symptoms and complications develop. Many conditions share early symptoms with diabetic gastroparesis, making a diagnosis more complicated. For this reason, the condition is often diagnosed after other medical problems are ruled out. These include infections and abnormalities in the gastrointestinal tract.
Treatment of Diabetic Gastroparesis
Although diabetic gastroparesis cannot be cured, it can be managed.
The cornerstones of diabetic gastroparesis treatment include targeting:
· Nutrition: A dietitian experienced in diabetic gastroparesis should be involved in meal planning. Some foods, like those that are acidic, spicy, or high in fat, can worsen gastroparesis symptoms. Carbonated beverages can also worsen symptoms. Because nutritional problems like vitamin and mineral deficiencies are common in those with the condition, a dietitian can help advise on the best foods to maintain good nutrition while minimizing symptoms.
· Hydration: Because dehydration is common in those with diabetic gastroparesis, maintaining good hydration is key to health. If meals cannot be tolerated, liquids may be taken to rest the stomach and promote good hydration.
· Blood sugar control: Adequate blood sugar control can help control symptoms of diabetic gastroparesis. In general, blood sugar should be maintained at or below 180 mg/dL. To prevent the swings in blood sugar that can occur with diabetic gastroparesis, your doctor may recommend a continuous blood glucose monitoring system to help you keep track of your blood sugar.
Some medications can be used to help the symptoms of diabetic gastroparesis. Generally, these medications are prokinetics, meaning that they work by helping the stomach to empty itself. These medications include:
· Metoclopramide (Gimoti, Reglan): This medication is the first-line therapy for diabetic gastroparesis. However, due to severe cardiac and central nervous system side effects, the medication should not be continued for longer than 12 weeks unless the benefit outweighs the risk.
· Domperidone: This investigational drug has not yet been approved by the FDA. However, it can be used to treat gastroparesis symptoms. Notably, cardiac side effects can limit the use of this medication.
· Macrolide antibiotics: Antibiotics like erythromycin and azithromycin (Zithromax) belong to the macrolide drug class. They can help increase movement in the gastrointestinal tract. However, their use should generally be limited to 4 weeks. Further, macrolide antibiotics can increase the risk of cardiac side effects like heartbeat irregularities.
Medications for other symptoms like nausea and vomiting may be prescribed, although they have not been extensively studied in diabetic gastroparesis. Other treatments, like gastric electrical stimulation or surgery, may also be options. Some data indicate that alternative medicine therapies like acupuncture may even be helpful in managing the condition.
Of note, some substances can worsen diabetic gastroparesis, because they slow the stomach’s emptying – opioid narcotics, heartburn medications, tobacco, and alcohol. Some anti-diabetes drugs can also slow the stomach’s emptying, exacerbating diabetic gastroparesis. This includes drugs like:
· Glucagon-like peptide 1 (GLP-1) agonists like semaglutide (Ozempic), liraglutide (Victoza, Saxenda), dulaglutide (Trulicity) and exenatide (Byetta)
· Dipeptidyl peptidase-4 (DPP-4) inhibitors like sitagliptin (Januvia), saxagliptin (Onglyza), alogliptin (Nesina, Vipidia) and linagliptin (Tradjenta)
· Pramlintide (SymlinPen)
Diabetic Gastroparesis Prognosis
Unfortunately, diabetic gastroparesis is linked to a higher rate of complications from diabetes. Specifically, it is linked to an increased risk of emergency department visits and hospitalizations. Although this may in part be due to the gastroparesis itself, it is important to remember that diabetic gastroparesis is also linked to having other complications from diabetes. For this reason, people with diabetic gastroparesis may also have complications and hospitalizations from their other diabetes-linked conditions like cardiovascular problems and kidney damage.
Other complications linked to diabetic gastroparesis include:
· Esophagitis, an inflammation of the esophagus
· Tears in the esophagus from chronic nausea and vomiting
· Dehydration, with kidney complications
· Abnormal electrolyte levels in your blood
· Indigestible masses of food in your gastrointestinal tract, which can sometimes cause a blockage
· High blood sugar emergencies like diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar state (HHS)
Krishnasamy, Sathya; Abell, Thomas L. “Diabetic Gastroparesis: Principles and Current Trends in Management.” Diabetes Therapy, June 22, 2018. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6028327/
Camilleri, Michael; Parkman, Henry P.; Shafi, Mehnaz A. “Clinical Guideline: Management of Gastroparesis.” American Journal of Gastroenterology, November 13, 2012. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3722580/
Young, Clipper F.; Moussa, Marianne; Shubrook, Jay H. “Diabetic Gastroparesis: A Review.” Diabetes Spectrum, August 2020. Retrieved from: https://spectrum.diabetesjournals.org/content/33/3/290