Prokinetics: What You Should Know – by Nancy Brown

Prokinetics: What You Should Know

by Nancy Brown

5/25/17

Prokinetics are class of medications that enhance motility for those who suffer from Gastroparesis and other slow motility diseases.  They are prescribed to improve the nausea, vomiting and bloating symptoms that people with those diseases commonly suffer from.

Prokinetics work by increasing movement of the stomach and intestines, improving overall digestion.  There is currently only one FDA approved prokinetic for Gastroparesis, though other prokinetics are prescribed off-label by doctors.  Off-label drugs were developed for other purposes, but have been found to improve motility for some Gastroparesis patients.  Below is a description of several prokinetics:

  Prokinetic Requires Rx Avail in US Recommended Duration of Use FDA Approved for GP
Metoclopramide

(Reglan)

YES YES No more than 3 months unless otherwise approved by doctor YES
Domperidone

(Motlium)

YES NO Depends on medical condition NO*
Erythromycin

(Erythrocin)

YES YES No more than 3 months unless otherwise approved by doctor NO
Tegaserod

(Zelnorm, Zelmac)

YES NO Restricted usage for emergency only NO

*Domperidone is actually approved for Gastroparesis patients but doctors must obtain advanced approval from the FDA to prescribe it.

Metoclopramide (Brand names include Reglan, Metozolv ODT, and PCP 100) is the only FDA approved drug for Gastroparesis.  It aids in digestion by causing stomach muscles to contract.  Metoclopramide also decreases incidents of nausea and vomiting.  Metoclopramide may cause tardive dyskinesia, a serious movement disorder.  The risk of tardive dyskinesia increases if Metoclopramide is used for longer than 12 weeks. Talk to your doctor about the risks and benefits of this medication.

Domperidone (Brand name Motilium) is approved in Canada, Europe, Japan and other countries, but not in the US. Originally developed to enhance breast milk production in lactating women, the FDA did not approve Domperidone due to risk of cardiac arrhythmias or cardiac arrest.  The FDA recognizes that Domperidone improves motility, nausea, and vomiting.  Doctors must request FDA approval to prescribe and order Domperidone.

Erythromycin is used to treat and prevent a variety of bacterial infections.  It speeds up motility, but its effectiveness reduces after several weeks of use.   Intravenous Erythromycin used in a hospital setting is effective for patients with severe Gastroparesis.  Lower doses of oral erythromycin improve Gastroparesis symptoms; unfortunately, side effects include stomach cramps and nausea.

Tegaserod (Brand name Zelnorm or Zelmac) is only available for emergency situations with approval by the FDA.  Originally developed for treatment of Irritable Bowel Syndrome (with diarrhea) or Chronic Idiopathic Constipation, Tegaserod increased stomach emptying and movement through the bowels.  Due to FDA concerns with cardiovascular side effects, it was removed for use in 2007.

The following drugs are in use for Gastroparesis, but they are not available in the US:  Levosulpiride, Mosapride Citrate, Itopride hydrochloride, and Pruclopride.

 

Future developments:

A clinical study has been completed in the US for Renzapride.  This drug is currently being developed by EndoLogic LLC for distribution.  Renzapride was tested for both gastroparesis and IBS-D.

Several other clinical trials are in process for evaluating drugs (beyond prokinetics) to treat Gastroparesis:  Promethazine, VLY-686, Prucalopride, RQ-10 (Parkinson and Gastroparesis) and Lixisenatide.  Please refer to https://ClinicalTrials.Gov and search for Gastroparesis for additional information on clinical trials.

Prokinetic medications may not be an option for all Gastroparesis patients.  Side effects may be too severe or the prokinetic may interact with other medications the patient is prescribed.  Gastroparesis patients often use prokinetics in combination with other treatment options or not at all.  Gastroparesis patients should work with their doctor to determine the best treatment plan based on the severity of gastroparesis.

 

About the author:

Nancy Brown lives in Virginia with her husband of 38 years, Ed.  They’re empty nesters and are enjoying retirement.  Prior to retiring, Nancy was a Manager of Requirement Analysis at Navy Federal Credit Union.

Resources for article:

http://webmd.com
http://www.aboutgastroparesis.org/medications.html
http://www.digestivedistress.com/motility-rx
http://www.medscape.com/viewarticle/514206_4
https://clinicaltrials.gov/ct2/show/NCT02130622?term=gastroparesis&recr=Open&rank=3
https://globenewswire.com/news-release/2017/01/03/902783/0/en/EndoLogic-Acquires-Renzapride-from-Alizyme-plc.html
https://www.fda.gov
https://www.ncbi.nlm.nih.gov

Malnutrition and Gastropares

Malnutrition and Gastroparesis

– by Rita Griffin and Jim Sliney Jr.

A major consequence of gastroparesis can be malnutrition. This is a direct result of the inability to properly absorb nutrients from food, or from minimal food intake. In severe cases of gastroparesis hospitalization may be required to correct the debilitating effects of dehydration and malnutrition.

The National Institutes of Health says that symptoms of malnutrition “may include fatigue, dizziness, and weight loss. Or, you may have no symptoms. To diagnose the cause of the problem, your doctor may do blood tests and a nutritional assessment. Treatment may include replacing the missing nutrients and treating the underlying cause.”

One of the greatest challenges of gastroparesis is learning how to maintain a nutritionally balanced diet through flare-ups. When suffering frequent flare-ups it is a struggle to figure out what can and can’t be eaten in order to meet vital nutritional needs. It is easy to get frustrated and lose hope.

Fortunately there are proactive adjustments one can make that can reduce the risks of becoming malnourished. According to the International Foundation for Functional Gastrointestinal Disorders (IFFGD) you can:

  • Work with a registered dietitian (RD) or nutrition support specialist (nurse or doctor) to design a dietary plan to meet your individual needs; understand how to use and maintain dietary and nutritional therapies.
  • Eat frequent, small meals that are low in fat and fiber. Fat, fiber, and large meals can delay stomach emptying and worsen symptoms.
  • Keep hydrated and as nutritionally fit as possible.
  • If you have diabetes, maintain good glucose control. Irregular stomach emptying can negatively affect blood sugar levels. Keeping your blood sugar under control may help stomach emptying.

Additionally, you can introduce multivitamins or liquid nutritional supplements (i.e. Ensure, Boost) to help meet nutritional needs.

Diet may be the most important discussion to have with your gastroparesis doctor. If your doctor is not well versed in diet and nutrition ask for a referral to a dietitian. Your gastroenterologist/dietitian can instruct you on foods to avoid, and the adequate amounts of vitamins and minerals certain foods can provide. It depends on each individual as to what form of diet can be tolerated. According to International Foundation for Functional Gastrointestinal Disorders, “Cooked or juiced vegetables are usually well tolerated. Consider adding nutritional supplements, such as caloric drinks, protein powder or protein bars.” Maintaining proper nourishment is the key.

The Liquid Diet

A full liquid diet is often used as a step between a clear liquid diet and a regular diet. Some GP patients unfortunately can only tolerate liquids.

Dr. Frank W. Jackson of gicare.com states that, “the purpose of the diet is to reduce symptoms and maintain adequate fluids and nutrition.” He goes on to discuss a 3 step diet plan:

  • STEP ONE DIET – Liquids – the goal is to prevent dehydration and keep the body supplied with vital salts and minerals. It consists of saltine crackers, fat free bouillon, Gatorade-type nutrient drinks and soft drinks. This diet has sodium and potassium but is otherwise not nutritionally sound. Step One shouldn’t last more than 3 days.
  • STEP TWO DIET – Fats – adding small amounts of fat and calories to the diet at less than 40 grams each day. Usually once Step One is completed, patients can tolerate Step Two. It can include skim milks, low fat cheese, eggs, peanut butter, some non-whole grain breads, well-cooked vegetables, and nutrient beverages as in Step One. Low in vitamins A, C, and Iron.
  • STEP THREE DIET – Long term – generally add fat with a limit of 50 grams a day. Still no fibrous foods, but fats can be increased to 50 grams a day. Also low in vitamins A, C, and Iron.

The information goes on to say that full liquid diets are usually low in iron, vitamin B12 and thiamine, as well as vitamins A and C and should be supplemented with a multivitamin. While the most common nutrient deficiencies seen in patients with gastroparesis (whatever their diet) are iron, vitamin B12, vitamin D, and calcium.

The The Gastroparesis Dysmotility Association in cooperation with Carol Rees Parish, RD and the University of Virginia, proposes a dietary plan based on “Food Zones”. The Food Zones seem to be an effective way to manage the changes needed when a flare up comes on. Beginning with clear liquids, as symptoms improve you can move up to full liquids, then to blended foods, then to soft foods, then to lower fat, full or solid foods. If a flare-up occurs, move back to the first zone (clear liquids) and begin moving back into each zone as you can tolerate.

food-zones

 

You shouldn’t try to manage all your nutritional needs on your own. The resources exist and your doctor or dietitian can help you tremendously. Remember to always monitor your diet, keep notes (that will help you and your medical team) and consult with your doctor about your specific nutritional needs.

 

Resources for article:

http://www.aboutgastroparesis.org/living-with-gastroparesis/prevention-management-tips.html

https://www.gicare.com/diets/gastroparesis-diet/

http://www.digestivedistress.com/what-to-eat-diabetics

Clinical Nutrition Week, Orlando FL 2/18-2/21

Clinical Nutrition Week 2017 in Orlando, FL

The American Society for Parenteral and Enteral Nutrition’s (ASPEN) Clinical Nutrition Week (CNW17) is a can’t miss conference for nutrition support professionals. Over 2,000 clinicians and researchers will gather for four days of educational and research programs aimed at improving patient care, on February 18-21, 2017 at the Orlando World Center Marriott in Orlando, Florida.

CNW17 features pre-conference courses, late-breaking research, and opportunities to meet nutrition support professionals from around the world. The pre-conference course, Functional

Medicine: The Optimal Approach to Intestinal Disorders, will provide an introduction to functional medicine and cover topics such as Case-Based Functional Nutrition Approach in a Nutrition Support Patient with Gastroparesis.

 

Visit the official CNW17 site for additional program information and to register.

Amitriptyline: A Sound Release

by Rita Griffin

Both constant and periodic vomiting and nausea plagued my son off and on for several years during high school. When he entered college in 2011, the frequency of stomach upsets increased. Numerous visits to the emergency room interrupted his college experience, and made his life unbearable.

In the fall of 2014, he was finally diagnosed as having idiopathic gastroparesis. The gastroenterologist, at that time, had first thought that he had cyclic vomiting syndrome. However, after performing the gastric emptying study, it was concluded that he indeed had gastroparesis.

Now that we knew what the problem was, it was decided by the doctor to prescribe nortriptyline, a tricyclic antidepressant, which helped alleviate the nausea for a while. The gastroenterologist was hesitant when he prescribed Reglan (metoclopramide), despite the overt side effects. Neither drug was helping my son, who at this time, was suffering emotionally from being sick, and missing college classes.

Another doctor with GP sufferers in his practice recommended placing my son on amitriptyline, also a tricyclic antidepressant. He also wanted him to cease gradually from the Reglan. My son stopped taking nortriptyline, and has now ceased from the Reglan.

Happily, I can say that amitriptyline has really aided my son with the nausea and vomiting associated with gastroparesis. Yet, he still has to avoid spicy, acidic foods to get the full potential of the drug.

Amitriptyline is used to help relieve symptoms of depression. My son takes his at bedtime, because it can cause drowsiness (his only complaint in the last six months). His local GI doctor and the GP specialist have both advised that they can increase his dosage, if needed. The highest dosage recommended is 150mg.

At first I was unaware that amitriptyline was used to treat depression. I could not understand how this could help with gastroparesis. After careful study, I learned that the drug works on the central nervous system to increase levels of certain chemicals in the brain. His GI doctor told us that stress could be a factor in our son’s sickness, because around the time of college exams and tests, his condition would worsened.

My son has shown no episodes of nausea, only rare occasions of pain. Pain is common with GP. When I first saw my son bent over in agony, I told him to stay calm and be more relaxed thinking that would help, but I did not really understand the pain he was experiencing. Based on my readings and information from the GP specialist doctor, the cause of GP related pain is unknown. The GP specialist who prescribed amitriptyline for my son gave an interesting finding in a report with the International Foundation for Functional Gastrointestinal Disorders (IFFGD, regarding tricyclic medications: “Low doses of trycyclic medications, such as amitriptyline, nortriptyline, and desipramine, have been shown to reduce pain in other functional gastrointestinal (GI) conditions and may reduce pain associated with gastroparesis.” The amitriptyline seems to help my son with pain.

As with all medications, there are diverse side effects. According to healthline.com the most common are “headache, constipation or diarrhea, confusion, numbness or tingling in arms and legs, unexpected weight gain or loss. The more serious side effects are chest pain, shortness of breath, weakness on side of body and slurred speech. There can also be interactions with herbs and vitamins.” So, it is important to check with your doctor before taking anything else while on amitriptyline.

Taking too much can lower your blood pressure and cause an irregular heart rate, confusion, hallucinations, and even convulsions. Your physician must monitor dosages. In fact, the Mayo Clinic advises that a doctor should check you at regular intervals for changes in dosage or to check for unwanted side effects. Amitriptyline may cause some people to be agitated, irritable, or display other abnormal behaviors.

Amitriptyline has given my son much needed relief from the nausea and vomiting associated with gastroparesis. In addition to the medication, he does chiropractic care, which has proven to be a positive benefit. My son has his spinal cord adjusted about once a month. The Chiropractor uses his hands “ to apply a specific application of forces to facilitate the body’s correction of nerve interference.” [Chiropractic First, page 67] This helps to relax his stomach muscles.

My son has no other medical conditions, and he gets a good report from his general practitioner visits. He has to be conscious of his diet. This has to be the most daunting aspect for him because he is young, and like young people, he wants to be able to eat whatever he wants. Usually, he does okay when he takes his medication and adheres to what he has to do to stay healthy.

Amitriptyline may not be a cure, but it has proven to be a constant relief for my son. Until a cure, he can at least experience a sound release from the pitfalls of gastroparesis.

Related Sources

www.healthline.com

www.MayoClinic.org

www.aboutgastroparesis.org

www.drugs.com

Rondberg, Terry A., D.C., Chiropractic First, The Chiropractic Journal, 1996 & 1998

Rita Griffin is a Georgia native. She has a Bachelor of Science degree in Psychology and worked for the Georgia Department of Transportation for 15 years. She loves studying the Bible, reading, traveling, writing, and meeting people. Rita has published 4 books of poetry. She is married with two sons. Rita is a volunteer writer for G-PACT.

 

We’re Partnering With The Mighty!

The Mighty Partnership with G-PACT

We’re thrilled to announce a new partnership that will bring our resources in front of The Mighty’s wide-reaching readership. We will now have a growing home page on The Mighty and appear on many stories on the site.TheMighty_logo w address

The Mighty is a story-based health community focused on improving the lives of people facing disease, disorder, mental illness and disability. More than half of Americans are facing serious health conditions or medical issues. They want more than information. They want to be inspired. The Mighty publishes real stories about real people facing real challenges.

We’re dedicated to helping people gastroparesis and related conditions. With this partnership, we’ll be able to help even more people.

We encourage you to submit a story to The Mighty and make your voice heard.

To the People Who Think My Chronic Illness Makes Me Weak

I see the way I’m looked at these days. Some of you look at me with pity, others with curiosity and still others with disdain. You think that because I have a chronic illness, I am weak and lazy and have no ambition. You see me as less than you. 

Don’t try to deny it, because I know how true it is. You see, I used to be you.

Before I became chronically ill, I didn’t realize that many people don’t have the energy to take a shower each day. Or that it’s not always possible to force yourself to complete a task because there’s just no way your body is able to cooperate. I didn’t realize that there are many diseases just waiting to ambush the innocent, diseases that cannot be cured or effectively treated. I certainly didn’t realize that I would one day be one of “those” people.

I thought I was strong, and then I found out what strong really is. Strong is just getting out of bed each morning. Strong is caring for your family when all you want to do is crawl into a hole and hide. Strong is navigating a health care system that is not always friendly to those of us with conditions that cannot be neatly categorized and handled by checking off treatment options on a predetermined list. Strong is persevering when you’re denied pain medications because you’re labeled a drug seeker, or fighting back when you’re told your insurance will not pay for a procedure or a medication because it’s not covered under your plan. Strong is the definition of each person who lives with a chronic illness.

You have no idea how hard we fight to maintain our lives after we become ill. We don’t want to stop working, exercising or socializing, but most of us cannot do these things any longer. We struggle with changing our ambitions and desires to fit within this new life we’ve been handed. Most people hate change and avoid it at all costs. We have no choice. 

We want you in our corner. But we are able to make it without you if we must. We’ve learned to find others like us and form bonds only we can understand. Our strength is not just for ourselves — it’s also for the millions battling our same enemies. Our shoulders are broad enough and strong enough to carry this load. Would yours be?

I believe life for the chronically ill is harder than it is for most people. We can’t always just fight through the pain, the fatigue, the desperation. Tasks that seem easy to the average person can push us to the edge of exhaustion and affect us for days afterwards. But please, don’t let any momentary weakness affect your perception of us. Because of our illnesses and how hard we have to fight each and every day, I believe we are stronger than most and more capable, too.

Read more: http://themighty.com/2015/11/to-the-people-who-think-my-chronic-illness-makes-me-weak/#ixzz3t5WApSlT