It is worth noting that gastroparesis can be cured by extendedperiods of normal blood sugars.
I've seen several relatively mild cases where special treatment was terminated after about 1 year, and blood sugar profiles remained flat thereafter.
At the same time, R-R studies im proved or normalized.
Since my late teens, I experienced severe daily belching, and burning in my chest.
These symptoms gradually eased off,and eventually disappeared, but only after thirteen years of nearly normal blood sugars.
My last R-R study was normal.
The "sacrifices" in lifestyle required for treatment of gastroparesis may really pay off months or years later.The vagus nerve doesn't control only stomach- emptying , there are a number of other complicationsresulting from impairedvagus function that can be reversed by maintaining normal blood sugars.
The regained ability to sustaina penileerectionisan im portant one for many of my male patients.
Once gastroparesis has been confirmed as the major cause of high overnight blood sugars and wide random variations in blood sugar profiles, we can begin to attempt to control or minimize its effects.
If your blood sugar profiles reflect significant gastroparesis, there is no way to get them under control by only juggling doses of insulin.
There's just too much danger of either very high or very low blood sugars for such approaches to work.
The only chance for effective treatment is to concentrate on improving stomach-emptying.
How do we do this?
We have four basic approaches.
First is the use of medications.
Sec-
Delayed Stomach-Emptying: Gastroparesis 365
ond is special exercises or massage during and after meals.
Third is meal plan modification utilizing ordinary foods, and fourth is meal plan modification utilizing semiliquid or liquid meals.
It's unusual for a single approach to normalize blood sugar profiles fully, so most often we try a combination of these four approaches, adapted to the preferences and needs of the individual.
As these at tempts start to smooth out blood sugars,we must modify our doses of insulin or ISAs accordingly.
The guidelinesthat we use to judge the ef ficacyof a given approach or combination of approaches are these: • Reduction or elimination of physical complaints such as early satiety,nausea, regurgitation, bloating, heartburn, belching, and constipation • Elimination of random postprandial hypoglycemia • Elimination of random, unexpectedhigh fastingblood sugars , probablythe most commonsignof gastroparesis that weencounter • Flattening out of blood sugar profiles Remember that the last three of these improvements may not be possible even without gastroparesis if you're following conventional dietary and medication regimens for "control" of your blood sugar.
For example, I know of no waythat will truly flatten out blood sugar profiles if you're on a high-carbohydrate diet and the associated large doses of insulin.
Medications That Facilitate Stomach-Emptying There is no medication that will cure gastroparesis.
The only "cure" is months or years of normal blood sugars.
There are, however, some pharmaceutical preparations that may speed the emptying of your stomach after a meal if your gastroparesis is only mild or moderate in severity (page 361, footnote).
These will help smooth out your blood sugar profiles after that meal.
Most diabetics with mild to moderate gastroparesis will require medication before every meal.
When gastroparesis is very mild, it may be possibleto get awaywith medication only before supper.
For some reason , perhaps because most people tend not to be as physically active after supper, and may havetheir largest meal of the day in the evening, digestion of supper appears to be more impaired than that of other meals.
It is also likely that stomach-emptying is slowerin the evening, evenfor nondiabetics.
Medications for gastroparesis may take the form of liquids or pills.
The question immediately arisesthat if pills must dissolve in the stom-
366 Treatment
ach to become effective, just how effective are they going to be? My ex perience is that they're of questionable value unlesschewed. The time required for a pill to dissolve in a paretic stomach is likely to be lengthy, and consequently the medication may take several hours to become effective. I generally prescribe only liquid medications or chewed tablets for stimulating gastric (stomach) emptying.
Cisapride suspension (Propulsid, Janssen Pharmaceutica) stimu lates the vagus nerve to facilitate stomach-emptying.
I usually pre scribe 1 tablespoon (25 mg), 15-30 minutes before meals for adults.
Many people will require 2 tablespoons for maximum effect.
Larger doses appear to be of little added value.
The manufacturer recom mends doses only up to 20 mg (2 teaspoons) for the treatment of esophageal reflux disease.
This condition is much more responsive to treatment than is diabetic gastroparesis, which as a rule requires the larger doses.
The package insert also recommends a bedtime dose, which serves no purpose for gastroparesis.
In many cases, cisapride alone will not bring about completestomach-emptying.We may add other medicationsif blood sugar profiles don't level off.
Cisapride can inhibit or compete for liver enzymes that clear cer tain medications from the bloodstream.
Your physician should there fore reviewallyour medications, especially antidepressants, antibiotics, and antifungal agents, before prescribing cisapride.
Stimulating the vagus nerve will also slowthe heart.
Sincediabetics with gastroparesis usually have an excessively rapid heart rate (more than 80 beats per minute) this is not often a problem.
Some individuals, however, have a cardiac conduction defect that abnormally slowsthe heart.
For such people,cisapridecan stop the heart, resultingin death.
Since, for many years, physicians have ignored this bold warning on the package in sert, a number of deaths actually have occurred.
The product has therefore been removed from the marketplace in many countries.
It is still available in the United States at no charge as an "investigational drug" if prescribed by a gastroenterologist who has been cleared for its use by the investigational review board of his hospital.
It is also available from pharmacies in New Zealand under the trade name Prepulsid (not a misspelling, a different brand name for the same product).
It may be purchased via the Internet after searching for Web sitescontainingthe words"pharmacy" and "NewZealand." Sucha pur chase will not be covered by your insurance (unless you happen to
Delayed Stomach-Emptying. Gastroparesis 367
live in New Zealand), and with shipping charges, it can be expensive. Furthermore, of late, manypharmacies in New Zealand refuse to ship to the United States. Since this agent works by stimulating the vagus nerve, it will not produce results if the nerve is almost dead , as with heart rate variability less than 13percenton an R-R study.
Super Papaya Enzyme Plus has been praisedby many of my pa tients for its rapid relief of some of the physical symptoms of gastro paresis, bloating and belching, for example.
Some claim that it also helps to level off the blood sugarswings caused by gastroparesis.
The product consists of pleasant-tasting chewable tablets that contain a varietyof enzymes (papain,amylase, proteases, bromelain,Upase, and cellulase) that digest protein, fat, carbohydrate, and fiber while they arestillin yourstomach.
You would normally chew 3-5 tablets during and at the end of each meal.
The tablets are available in most health food stores and are marketed by American Health, (631) 567-9500, Ronkonkoma, NY 11779.
Theyare also available from Rosedale Phar macy, (888) 796-3348.
Someof mykosherpatients use a similar prod uct called Freeda All Natural Parvenzyme, which is distributed by FreedaVitamins,36 EastForty-firstStreet,NewYork, NY 10017, (800) 777-3737, and on the Web at freedavitamins.com.
The small amount of sorbitoland similar sweeteners contained in these productsshould not have a significant effect on your blood sugar if consumption is limited to the above dose.
Domperidone (Motilium, Janssen Pharmaceutica) is not yet avail ablein the United States.
It can be purchasedin Canada,the U.K., and perhaps some other countries.
Pharmacies in Canada are no longer permittedto ship medications to the United States unless theyarepre scribed bya Canadian physician.
It therefore may be necessary to pur chase it elsewhere viathe Internet.* Since it is not available asa liquid, weaskpatientsto chew2 tablets (10mgeach) 1hour beforemeals and to swallow with 8 ounces of water or diet soda.
I limit dosing to 2 tablets because largerdoses can cause sexual dysfunction in men and absence of menses in women.
These problems resolve when the drug
*A number of Canadian pharmacies for an additional charge of $5 can secure prescriptions for distant foreign patientsfromCanadianphysicians. One of these is Murray Shore Pharmacy, (800) 201-8590.
368 Treatment
is discontinued. Since it works by a mechanism different from those of the preceding products, its effects can be additive (that is, useful with other preparations). Janssen may market a liquid form of this product in the United States at some time in the future. In the meantime, some gastroenterologists maybe ableto prescribe it, likePropulsid,as an in vestigational drug.
Metoclopramide syrup may possibly be the most powerfulstimu lant of gastricemptying.It worksin a fashionsimilarto domperidone, by inhibiting the effects of dopamine in the stomach.
Because it can readily enter the brain, it can cause serious side effects, such as som nolence,depression, agitation,and neurologicproblems that resemble Parkinsonism.These side effects can appear immediatelyin some in dividuals or only after many months of continuous use in others.
Be cause gastroparesis often requires doses high enough to cause side effects, I use this medicationinfrequently and limit dosingto no more than 2 teaspoons 30 minutes before meals.
If you use metoclopramide, you should keep on hand the antidote to its side effects , diphenhydramine elixir (Benadrylsyrup).
Twota blespoons usually work.Ifside effects become serious enough to warrant useof the antidote, the metoclopramide should be immediately and per manentlydiscontinued.
Abrupt discontinuation of metoclopramide has been reported to cause psychotic behavior in two patients after continuous use for more than three months.
This information might suggest to your physician that it be graduallytapered off if it is to be discontinued af ter even two months of continuous use.
Erythromycin ethylsuccinate is an antibiotic that has been used to treat infections for many years.It has a chemicalcomposition that re sembles the hormone motolin, which stimulates muscular activity in the stomach.
Apparently, when stimulation of the stomach by the va gus nerve is depressed,as with autonomic neuropathy, motolin secre tion is diminished.
Three papers deliveredto the 1989annual meeting of the American Gastroenterological Association demonstrated that this drug can stimulate gastricemptying in patients with gastropare sis.
In people without gastroparesis, erythromycin can cause nausea, unless taken after drinking fluids.
I ask my patients to drink two glasses of water or other fluid before each dose.