mycin ethylsuccinate oral suspension just before meals.
Westart with 1 teaspoon of the 400 mg/tsp concentration, and increase to several teaspoons if necessary.
As each teaspoon of this suspension contains 3.5 grams of sucrose (table sugar), it will be necessary to increase slightly the doses of insulin covering mealsto reduce blood sugar ele vation while this medication is used.
If the liquid is kept in a refriger ator,the taste beginsto deteriorate after 35days.
At room temperature, taste deteriorates after 14 days.
I have seen no side effects from this medication.
I insist that patients who use it chronically take 1 probi otic capsule (such as Florastor [saccharomyces boulardii], Culturelle Lactobacillus GG, or Nature's Way Primadophilus Reuteri) at least 2 hours before or after each dose.
This is to restore to the intestine nat ural bacteria that can be destroyed by this antibiotic.
It is also wise to consume one 150 mg fluconazole tablet per month to inhibit growth of fungus in the GI tract or vagina.
I have not found erythromycin to be especially effective for treating gastroparesis, despite published studies.
Betaine hydrochloride with pepsin is a potent combination that can predigestfood in the stomach by increasing acidity and adding a powerful digestive enzyme.
It can be procured at most health food stores or at Rosedale Pharmacy.
Because of its acidity it should not be used by those with gastritis, esophagitis, or stomach/duodenal ulcers.
Food that has been predigestedwill more likely pass through the nar rowedpyloricvalve of gastroparesis.
We initially use 1tablet or capsule midmeal.
If no burning is perceived, we increase the dose to 2 and then eventually 3 tablets or capsulesspaced evenlythroughout subse quent meals.
It should never be chewed or taken on an empty stomach.
Since betaine HC1 with pepsin, unlike cisapride, does not attempt to stimulate the vagus nerve, it is frequentlyof value for even severecases of gastroparesis.
Nitric Oxide Agonists Although the aforementioned agents can be veryeffective when gas troparesis is mild, their effectiveness in minimizing blood sugar un certainty after meals diminishes when this condition is more severe. Myfrustration in trying to circumvent this problem has led to my in vestigation of a class of substances called nitric oxide agonists. Such agents are currently being used to relieve effects of angina in patients
370 Treatment
with cardiac disease.
Since they work by relaxing the smooth muscle in the walls of coronary arteries, I assumedthat they could also relax the smooth muscle of the pyloricvalve.
My initial trial was with a medication called isosorbide dinitrate.
I had it prepared asa suspension in almond oil (with flavoring) so that it could coatthe pylorus and work directiy upon it.
I had it compounded in a concentrate of 5 mg/tsp (1 mg/ml).
I waspleased to seethat my as sumption proved correct , it was veryeffective fornearlyallofmy pa tients who used it.
Thus far, it appears to be more successful than any of the agents described above.
Nevertheless, it is only partially effective for more severe cases of gastroparesis.
This formulation can be prepared by any compounding chemist (see footnote, page 202).
The only adverse effect I've observed has been headache in about 10 percent of the users.
Although the head ache usually resolves after several days of use, I try to prevent it by startingwith very smalldoses that canthen be gradually increased.
I therefore recommend that initially lh teaspoon be taken 30-60 minutes before dinner.
After one week, we increase the dose to 1 tea spoon.
If this fails to level off blood sugars at bedtime and the follow ing morning, we continue 1 teaspoon for a week and then increase it to 2 teaspoons.
If this is not fully effective, we then increase to 3 tea spoons.
If this dose doesn't do the trick, I discontinue the treatment, as further increases areunlikely to be effective.
If 1-3 teaspoons work, we then use the same dose 30-60 minutes before each meal.
It's been un usual for this formula to be totallyineffective.
The liquid must be vig orously shaken before use.
If you have a cardiac condition, isosorbide dinitrate should not be used for gastroparesis unless approvedby your cardiologist.
Unfortunately, isosorbide dinitrate usually stops working after a period of weeks to months.
I therefore attempt to increase effective ness and lower blood sugar levels by applying a chemically similar product to the skin direcdy over the pylorus.
What I prescribe is a ni troglycerine skin patch.
These are available by prescription at any pharmacy in strengths of 0.1,0.2,0.4, and 0.8 mg.
The patch is placed over the pylorus, which is located on the midline of the abdomen above the navel, about 1V4 inches (37 mm) below the middle of the lowest rib where it forms an invertedV.
The patch is applied on arising in the morning and removed at bedtime.
We start with the 0.1 mg patch and increase the sizeeachweek if there areno adverse effects.
As with isosorbide dinitrate, nitroglycerine should not be used for gas-
Delayed Stomach-Emptying. Gastroparesis 371
troparesis without your cardiologist's approval if you have a cardiac condition.
Anotheralternative is the clonidine adhesive skinpatch.This prod uct is sold as Catapres in allpharmacies to lower blood pressure and requires a prescription.It is a powerful smooth musclerelaxant.It can, however, cause somnolence (sleepiness) in some people.
We therefore start at the smallest size (1 mg) for the first weekand increase it to 2 mg for the second week, then 3 mg for the third weekand thereafter.
Althougheach patch willwork for a week on most people,we remove it at bedtime and replace it the next morning.
Since the patch's adhe siveness will be reduced after it's removed, you can use paper tape to keep it attached after the first day.
If it causes tiredness, we lower the patch dosage or discontinue it.
Like the aforementioned nitric oxide agonists, it can stop working eventually.
If it has been effective and stops working, we discontinue it and restart it after a couple of months.
Some patients find that a patch will stop working after 3-4 days.
For these people, we change to a new patch midweek.
The reason we remove the clonidine (or nitroglycerine) patch from the skin at bedtime is to slowdown the developmentof tolerance to its action which eventually occurs.
I alsorecommendalternatingdaytime skin patches, one weekon clonidine and one week on nitroglycer ine , alternating over and over.
Exercises That Facilitate Stomach-Emptying The pareticstomach maybe described as a flaccid bag,deprived of the rhythmic muscular squeezingpresent in a stomach that has a properly functioning vagus nerve.
Any activity that rhythmically compresses the stomach can crudely replicate normal action.
You may perhaps have observed how a brisk walk can relieve that bloated feeling.
I thereforestronglyrecommendbrisk walking for an hour immediately after meals , especially after supper.
A patient of mine learned a trick from her yoga instructor that eliminated the erratic blood sugar swings caused by her moderate gastroparesis.
The trick is to pull in your belly as far as you can, then push it out all the way.
Repeat this with a regular rhythm as many times as you can, immediately after each meal.
Over a period of weeks or months, your abdominal muscles will become stronger and stronger, permitting progressively more repetitions before you tire.
Eventually shoot for several hundred repetitions , the more the bet-
372 Treatment
ter. This should require lessthan 4 minutes of your time per hundred reps, a small price to pay for an improvement in your blood sugar profiles. Another patient discovered an exercise that I callthe "back flex." Sit or stand while bending backward as far as you can. Then bend for ward, about the same amount. Repeat this as many times as you can tolerate. Although these exercises may sound excessively simple, even silly, they havehelped some peoplewith gastroparesis.
Mechanical Aids
Hand-held massager. One product of possible value is a variable- speed hand-held massager that can be placed over the stomach (left side of the abdomen just below your ribs). A 15-30 minute massage mightspeedstomach-emptying. Thisproduct iscalled Programmable Percussion Massager with Heat#HF755 and is available from Sharper Image Corp., (415) 445-6000 or online at www.sharperimage.com. Usethe largestof the five setsof removable heads.
Chewing Gum Can Make a Big Difference The act of chewing produces saliva, which not onlycontains digestive enzymes but also stimulates muscular activity in the stomach and tends to relax the pylorus.
Orbit is a delicious "sugarless" gum with a long-lasting flavor.
It contains only 1 gram of sugar per piece and so will have littleeffect upon yourbloodsugar.* Chewing gumfor at least 1hour aftermeals is a veryeffective treatmentof gastroparesis outside of major dietarychanges.
Don't chew one piece afteranother,because the grams of sugar can add up.
Meal Plan Modifications, Utilizing Ordinary Foods Moreoften than not,changes in yourmeal planwill prove moreeffec tive thanmedication. The problem isthatsuch changes are unaccept able to many patients. We usually proceed from most to least convenient in six stages:
Another worthwhile chewing gumisXlearDent Each piece contains %gramof xylitol, which can kill the bacteria that cause tooth decay. To order it, phone (877) 599-5327, or visit the Web at www.xlear.com.