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Saturday, April 13, 2013

What Can be Done when Gastroparesis Treatments Don’t Seem to Help

What can be done when Gastroparesis Treatments don’t Seem to Help

Many people with gastroparesis will respond to medical management with some dietary modification. However, medication failures or side effects are common. Many physicians have little knowledge or experience with treating gastroparesis.


Some practical things to consider when treatment does not seem to help include:

• Check the diagnosis
• The cause matters
• Review the diet
• Consider other medications
• Treat the pain
• Manage the psychosocial aspects
• Know when to consider surgery
• Be persistent and be careful




Check the Diagnosis

Nausea is the hallmark symptom of gastroparesis. Other medical problems should be considered when nausea is not a prominent symptom.

Dyspepsia is characterized by pain/burning in the mid-upper abdomen and/or bothersome fullness following a normal sized meal and/or inability to complete a meal (early satiety). People with esophageal diseases such as GERD or achalasia can have abnormal gastric emptying studies.

For more about these conditions, please click in the links below in all caps and in bold:

ACHALASIA
CYCLIC VOMITING SYNDROME
DYSPESIA
GERD
INTESTINAL PSEUDO-OBSTRUCTION
RUMINATION SYNDROME (as a side note, I have this as well and the doctor told me to do DIAPHRAGMATIC BREATHING to control it).

Nausea may be a secondary symptom in people with countless other medical problems. Cyclic vomiting syndrome (CVS) is a disorder where otherwise completely healthy people have stereotypical intermittent episodes of severe nausea, vomiting, and abdominal pain. People with intestinal pseudo obstruction have prominent symptoms of bloating and severe constipation. Rumination syndrome is characterized by constant regurgitation and either vomiting or re-swallowing food or drink soon after eating. Small bowel obstruction should be considered in people who have had previous abdominal surgery.




The Cause of the Gastroparesis Matters

In diabetic gastroparesis it is important to control the blood sugar, as intestinal motility is impaired when the blood sugar is elevated. Intravenous erythromycin should be considered in hospitalized patients with diabetes. Unfortunately, erythromycin seems to be beneficial for only a few days at a time.

Patients with idiopathic post-viral gastroparesis usually improve over the course of time, ranging from several months to one or two years. During that period it is important to consider that any irreversible surgical procedures not be performed in these patients to treat idiopathic post-viral gastroparesis.

Identifying and treating any underlying systemic disorder may rarely help, and is worth the effort.




Review the Diet

Many physicians tend to skip dietary recommendations, although it is the area of most interest to patients. It is important to review the low-fat, low-fiber diet and to discuss nutritional supplements.

Rarely, feeding tubes and total parenteral nutrition are necessary. Enteral feeding tubes should be placed in the jejunum, not the stomach. These should not be considered early in the course of the patient’s illness, as they are not without risk. They must be carefully managed to avoid serious complications like infection.

You can review the Mayo diet and recipes that are GP friendly in another one of my articles by clicking HERE.




Consider Other Medications

The utility of the prokinetic agents is often limited by their side effects. There is a good bit of anecdotal evidence that medications like amitriptyline or nortriptyline can decrease the sensation of nausea. The typical dose is 25–50 mg at bedtime, which is well below the dose that is required to treat depression. A doctor can check blood levels, and modify the dose accordingly. Side effects, including blurry vision, urinary retention, sleepiness and constipation are uncommon because of the low dose.

Bacterial overgrowth (SIBO) may accompany gastroparesis. The main symptom is bloating. Judicious use of antibiotics and probiotics may be helpful in the management of these symptoms.

It is difficult for patients with nausea and vomiting to tolerate oral medications. Obviously, hospitalized patients should receive intravenous medication. Outpatients may do better with medication that dissolves in the mouth.

Reports from highly specialized (tertiary) medical centers that often see people with severe gastroparesis suggest that bloating is a common symptom. Bloating impairs quality of life. Bloating severity appears related to intensity of other gastroparesis symptoms but is not affected by gastric emptying rates. Antiemetics, probiotics, and antidepressants with significant norepinephrine reuptake inhibitor activity may help.

Here are some natural remedies recommended by friends:

This one is for gas and bloating called GAIA.

The second one is for PEPPERMINT OIL. It combats indigestion, bloating, gas, IBS, and skin irritations. I usually drop a few drops into my tub and soak in it as well.

Leanne suggests IBEROGAST as a natural remedy to help with Gastroparesis. You can find it on Amazon HERE.

Melony suggests ACUPUNCTURE. She writes, “I had been using acupuncture for treating my Gastroparesis for about a 6 month period and received great results, it requires twice weekly visits usually, unfortunately it is something that must be continued to continue getting results. Once you stop treatment you will no longer see the benefits. Also insurance usually will not cover it, the clinic I was going to was about $50 a visit. Acupuncture involves the insertion of extremely thin needles (about half the size of a strand of hair) through your skin at strategic points on your body (usually back stomach arm chest and top of feet however every acupuncturist might do it slightly differently, you then lay on a bed after needles have been inserted, they remain in and you are covered by a thin foil like blanket, relaxing sounds will be put on a radio and you lay there for about half an hour) Acupuncture is a key component of Traditional Chinese medicine, a few small studies have been done regarding the effectiveness of acupuncture for GP. One small study published in the Journal of Traditional Chinese Medicine in 2004 looked at the effects of acupuncture on the symptoms of Gastroparesis in thirty-five people. One group received only acupuncture, a second group received a Gastroparesis medication called domperidone, and a third group received no treatment. The results were encouraging. The group who received acupuncture experienced more Gastroparesis relief than either of the other two groups. Even though domperidone is one of the more effective medications for treating Gastroparesis, in this small study, acupuncture outperformed it. I agree with those results as it was the best I had felt since getting sick, it is not for everyone due to the price (that is also why I stopped) but I feel it is worth looking into for anyone not finding good success with managing their GP!”

Margaret writes, "I buy over the counter NAUZENE CHEWABLES for Nausea and they are awesome. They work for me most of the time when I have nausea and are quick, usually work in less than 5 minutes. I have never had to go on a prescription medicine for nausea. They are cheap too, about, $5.50 for a box of forty. Also, I like CRYSTALLIZED GINGER CHEWS. They are good for stomach upset and nausea. Love ginger tea too. I drink about two cups everyday."

Annie writes, "A couple of things my daughter Faith does: DGL from a health food store is good at keeping mild acid reflux under control and it doesn't slow down motility. DOTERRA has a couple of essential oils that are helpful: Deep Blue for pain and Frankincense for nausea. She mixes a drop or two with coconut oil and massages them where ever needed. Though it's not a medicine per se, Faith also uses MEDITATION to help with the pain."

Personally, I recommend QUEASE EASE and PREGGIE DROPS. Quease Ease is a blend of peppermint ginger lavender spearmint oils. You inhale it and the feeling of nausea subsides. It was recommended to me by my good friend Melony and I carry it with me everywhere. The Preggie Drops are Kosher, Vegan, and Gluten Free. They help morning sickness and are given to cancer patients to ease their nausea. In addition, the Preggie Drops alleviate dry mouth and provide quick calories and energy when you need it.

Shannon writes, "Pro-biotics, Super Digest away, Green Smoothies, and Epsom Salts baths, to deal with the constipation drink a glass of warm water with Epsom salts, also ice down the stomach for pain, Earth Fares Stomach comfort tea for the cramping and pain. It has chamomile, licorice and ginger. Lemon water to help with digestion of foods. Just a few that I have used and truly work for me."

Sabrina writes, "SUPER PAPAYA ENZYME for motility, PROBIOTICS, and HYPERICUM for pain cramping. I also take sublingual B12 complex, vitamin gummys [note, you may want to use chewables like Flinstone's vitamins because gummy vitamins have a hard time with digestion] and have tried ginger tea."

Julie writes,"Sipping dill pickle juice will fix the nausea. Also, LEMON MINT EMETROL is also a miracle worker for nausea."

Mary Ann writes, "I recommend ALL-ZYME. This focused formula delivers the plant-sourced enzymes amylase, protease, lipase, and cellulose to aid in the digestion of protein, carbohydrates, fats and dietary fiber, especially for those with diets high in processed or refined foods. All-Zyme Double Strength™ can also support occasional indigestion, gas, bloating, and constipation."

Kristin writes, “I use Coke-a-Cola for my upset tummy. It helps me after I have a really bad vomiting session so that I won't have a repeat attack.”

Jennifer writes, "I take DIGESTIVE ADVANTAGE probiotics."

Kristen writes, "I take ginger and peppermint for nausea (I usually do this in tea form). Fever-few, turmeric, devil's claw, St. John's wart, and Valerian root for pain. Fennel, ginger, parsley, garlic [side note, garlic is against the Mayo GP Diet List, so be careful], dandelion, and dill pickles work for gas and bloating, believe it or not."

Millie writes, "Epsom Salt Baths & Castor Oil Packs!"

Wyld Heart writes, "Sniffing spearmint helps my nausea sometimes when the rest of the house is cooking something nasty and smelly, like REAL food."

Shannon (Page Creator of One Million Likes for Gastroparesis) writes, "Pro-biotics, Super Digest away, Green Smoothies, and Epsom Salts baths, to deal with the constipation drink a glass of warm water with epsom salts, also ice down the stomach for pain, Earth Fares Stomach comfort tea for the cramping and pain. It has chamomile, licorice and ginger. Lemon water to help with digestion of foods. Just a few that I have used and truly work for me."

Windy writes, "Crystallized ginger is the only thing I use."

Pauline writes, "Snap Windy I only use ginger as well, but I also don't think I have it as severely as some others. Before I discovered ginger I would make myself throw up to empty my stomach and have a really warm shower to deal with it. Within an hour of this I would usually feel hungry again, but for the next two days I would only eat smaller amounts of really safe foods. Now if I have a slight feeling in the GP direction or have had a meal I'm worried about I'll take some ginger and it almost always works."

This is a medication that has been subscribed by GI doctors all over the US but you should research the side effects first before you take it. The medication is Domperidone and I will have to keep updating the information on it because it constantly changes. As it stands right now,

"WHAT THE FDA SAYS ABOUT DOMPERIDONE

Domperidone – How to Obtain

Domperidone is not currently a legally marketed human drug and it is not approved for sale in the U.S. On June 7, 2004, FDA issued a public warning that distributing any domperidone-containing products is illegal. FDA also issued an Import Alert instructing FDA field personnel to detain shipments of finished drug products and bulk ingredients containing domperidone, and refuse admission into the US. FDA took this action because of the concern about the potential serious health risks associated with the use of domperidone by lactating women to enhance breast milk production.

The risks of cardiac arrhythmias, cardiac arrest, and sudden death outweigh any potential benefit of domperidone in healthy lactating women. In addition, the concurrent use of certain commonly used drugs, such as erythromycin, could raise blood levels of domperidone and further increase the risk of serious adverse cardiac outcomes. In several countries where the oral form of domperidone is marketed, the drug's labeling specifically warns that nursing mothers should not use it. Furthermore, domperidone is excreted in breast milk, exposing a breastfeeding infant to unknown risks. However, FDA continues to recognize that there are some patients with severe gastrointestinal motility disorders that are difficult to manage with available therapy for whom domperidone’s potential benefits may justify its potential risks.

While there are currently no pharmacies that are authorized to compound domperidone under the Expanded Access program, domperidone may be obtained under certain circumstances, as described below.


Submit an IND

Patients 12 years of age and older with certain gastrointestinal (GI) conditions may be able to receive treatment with domperidone through an expanded access investigational new drug application (IND). These conditions include gastroesophageal reflux disease with upper GI symptoms, gastroparesis, and chronic constipation. Patients who are eligible to receive domperidone have generally failed standard therapies. Expanded access INDs facilitate access to investigational drugs (such as domperidone) for patients with serious diseases or conditions for which there is no comparable or satisfactory alternative therapy to diagnose, monitor, or treat the patient’s disease or condition. In addition to other applicable requirements, an IND must be in effect prior to the importation, interstate shipment, and administration of domperidone.

Contact Us
Physicians interested in submitting an expanded access IND for domperidone can obtain more information by contacting DDI (below) to request the Domperidone Packet which contains the required forms, instructions, and answers to most questions.

Division of Drug Information (DDI):
toll free at:
(855) 543-3784 FREE or
(301) 796-3400
email: druginfo@fda.hhs.gov
http://www.fda.gov/Drugs/DevelopmentApprovalProcess/HowDrugsareDevelopedandApproved/Appro valApplications/InvestigationalNewDrugINDApplication/ucm368736.htm

FDA Talk Paper: FDA Warns Against Women Using

Unapproved Drug, Domperidone, to Increase Milk
Production

June 7, 2004

In response to reports that women may be using an unapproved drug, domperidone, to increase milk production (lactation), the Food and Drug Administration (FDA) is warning breastfeeding women not to use this product because of safety concerns. Today, FDA also issued six letters to pharmacies that compound products containing domperidone and firms that supply domperidone for use in compounding.

The Agency also is issuing an Import Alert which alerts FDA field personnel to be on the lookout for attempts to import this drug so that it can be detained and refused admission into the U.S. if appropriate.
FDA took these actions because it has become aware that some women who breastfeed and/or pump breast milk are purchasing this drug, domperidone, from compounding pharmacies and from sources in foreign countries to increase breast milk production. Domperidone may increase the secretion of prolactin, a hormone that is needed for lactation.

Although domperidone is approved in several countries outside the U.S. to treat certain gastric disorders, it is not approved in any country, including the U.S., for enhancing breast milk production in lactating women and is also not approved in the U.S. for any indication.

The agency is concerned with the potential public health risks associated with domperidone. There have been several published reports and case studies of cardiac arrhythmias, cardiac arrest, and sudden death in patients receiving an intravenous form of domperidone that has been withdrawn from marketing in a number of countries. In several countries where the oral form of domperidone continues to be marketed, labels for the product contain specific warnings against use of domperidone by breastfeeding women and note that the drug is excreted in breast milk that could expose a breastfeeding infant to unknown risks. Because of the possibility of serious adverse effects, FDA recommends that breastfeeding women not use domperidone to increase milk production.
The FDA recognizes the immense health benefits that breast milk provides for a nursing infant and is taking these actions today not to discourage women from breastfeeding but rather to warn them not to use this particular drug while they are breastfeeding.

The letters issued by FDA today stated that all drug products containing domperidone (whether compounded or not) violate the Federal Food, Drug, and Cosmetic Act (the Act) because they are unapproved new drugs and misbranded. In addition, distribution within the U.S., or importation of domperidone-containing products, violates the law. FDA informed the warning letter recipients that further violations of the Act may result in enforcement actions including seizure and injunction.

http://www.fda.gov/Drugs/DrugSafety/InformationbyDrugClass/ucm173886.htm
"







Treat the Pain

If you have never seen a Gastroparesis Attack, then check out my friend Tanya's VIDEO. It's something all of us with Gastroparesis suffer with on a day to day basis.

Abdominal pain may be overlooked in gastroparesis. However, controlling abdominal pain can be the key to success in the management of many patients. Pain does not correlate with gastric emptying. Non-steroidal anti-inflammatory drugs (NSAIDs) may help. Low dose tricyclic medications, such as amitriptyline, nortriptyline, and desipramine, have been shown to reduce pain in other functional GI conditions and may reduce pain associated with gastroparesis. Other drugs found useful in treating neuropathic pain may be tried. Opiates, or narcotics, should be avoided.
Manage the Psychosocial Aspects

Not surprisingly, anxiety and depression are very common in people with chronic debilitating illnesses. The physician and staff need to have compassion and patience. If necessary, psychological consultation should be considered. Low dose tricyclic medications do not treat anxiety or depression. Real emotional disorders require real psychological treatment. Appropriate treatment can lead to improvement in the GI symptoms.

Patients with an eating disorder may be given a diagnosis of gastroparesis. However, it is probably more common for patients with gastroparesis to be accused of having an eating disorder, rather than actually having one.




When to Consider Surgery

Patients failing medical therapy should have a thorough evaluation before considering surgical therapy. Surgical procedures all have inherent risks that need to be carefully weighed and understood. Most surgical treatments are irreversible, but work in carefully selected patients, having the correct surgery done, by an experienced and accomplished surgeon.

Be Persistent and Be Careful!

Most medications work only less than half of the time. Nonetheless, most people will respond to some therapy. If a medication causes side effects, consider a lower dose. If it doesn’t work, try something else. Combining medications can be helpful. Keep hydrated and as nutritionally fit as possible.

When treatment is failing and there appear to be no other options – whether you are the patient or the physician – get another opinion. Persistence pays off, as most people with gastroparesis ultimately will do well.

Source of the Article is HERE.
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