Sufferers who obtain therapy with a glucagon-like peptide-1 (GLP-1) receptor agonist, reminiscent of semaglutide, might expertise delayed gastric emptying as a result of drug’s mechanism of motion (MOA).1 Signs might embody nausea, vomiting, heartburn, ache, or bloating.2 Nonetheless, the signs of delayed gastric emptying ensuing from GLP-1 receptor agonists could also be much like signs of gastroparesis.3
Current studies have revealed that sufferers who obtain semaglutide-containing drugs, reminiscent of Ozempic® and Wegovy®have developed gastroparesis.4,5 Given the resemblance in signs between delayed gastric emptying and gastroparesis, it’s important for clinicians to realize consciousness of the most effective method for managing gastroparesis in sufferers receiving GLP-1 receptor agonists. How ought to clinicians carry out a differential analysis? What are counseling factors sufferers ought to obtain relating to GLP-1 receptor agonists’ MOA?
To make clear the aforementioned questions and extra, we spoke with 2 clinicians: Nancy Bono, DO, chair of household medication at New York Institute of Know-how Faculty of Osteopathic Medication (NYITCOM), and Eleanor Yusupov, DO, assistant professor of scientific specialties at NYITCOM.
What are probing questions clinicians ought to ask sufferers who are available in with generic gastric signs with a view to carry out a differential analysis for gastroparesis?
Dr Bono: Begin with a evaluate of system (ROS), a listing of physique methods obtained by asking a sequence of inquiries to establish indicators and/or signs the affected person could also be experiencing or has skilled. This consists of constitutional signs — for instance, fever and weight reduction — in addition to gastrointestinal (GI) signs like stomach ache, constipation, diarrhea, heartburn, lack of urge for food, nausea, and vomiting.
Dr. Yusupov: Sufferers must be requested in-depth questions relating to their GI signs, together with nausea, vomiting, stomach ache, stomach distention, painful or tough swallowing, bloating, early satiety, diarrhea, or constipation. As well as, the presence of fever, weight reduction, location, and outline of the stomach ache, in addition to any affiliation of signs with meals must be ascertained. Sufferers must be requested about their drugs, historical past of diabetes, motility issues, and surgical procedures.
What are some key differential diagnoses clinicians ought to be mindful when sufferers current with extended broad generic gastric signs, reminiscent of nausea, vomiting, and diarrhea, if they’re a affected person with sort 2 diabetes or weight problems who initiated a GLP-1 receptor agonist? What’s the benchmark for these signs being anticipated hostile occasions of latest remedy vs a priority?
Dr Bono: You could evaluate the affected person’s weight-reduction plan. One advice could be smaller meals, which will help alleviate nausea by decreasing the quantity of meals that must be digested directly. Smaller, extra frequent meals will help to stabilize blood sugar ranges, which, in flip, will help to stop nausea brought on by dips in blood sugar. One other advice could be to keep away from high-fat meals, fried meals, and fatty meals, together with quick meals, in addition to meals excessive in sugar, which are usually the hardest for the physique to digest and the more than likely to trigger nausea whereas taking a GLP-1 medicine.
Hydration can be key to stopping or minimizing nausea. Zofran may be prescribed to reduce nausea for a number of days. The principle concern is to cease therapy once you suspect pancreatitis, the ache felt within the higher left aspect or center of the stomach. The ache could also be worse inside minutes after consuming or ingesting at first, extra generally if meals have a excessive fats content material. It could additionally develop into fixed and extra extreme, lasting for a number of days. Amylase and lipase exams are used to detect pancreatitis. If the enzymes circulating in your bloodstream are elevated, then the medicine must be stopped.
Dr. Yusupov: Clinicians ought to be mindful viral sickness, acute pancreatitis, gallbladder illness, and kidney harm. Nausea, vomiting, diarrhea, or constipation are widespread with initiation or dose enhance of GLP-1 agonists. Nonetheless, we get involved any time the signs are extreme, don’t enhance rapidly, or are related to stomach ache.
If a affected person is experiencing medication-induced gastroparesis attributable to semaglutide, what patient-specific and disease-specific elements ought to physicians take into account when figuring out the subsequent steps to handle the gastroparesis?
Dr Bono: Reglan (metoclopramide). This medicine will increase the actions in your digestive system, serving to the meals to move via extra rapidly and effectively to deal with gastroparesis.
Dr. Yusupov: Delayed gastric emptying is anticipated whereas taking semaglutide; it’s associated to the MOA of this drug. Nonetheless, particular person affected person tolerability of the related signs is essential. Most sufferers expertise gentle GI signs and study to handle them. Due to this fact, they can proceed therapy. If signs persist regardless of dietary and life-style modifications or develop into extreme, semaglutide must be stopped.
What therapy choices must be thought-about for sufferers who develop gastroparesis when on a GLP-1 receptor agonist? Does administration for gastroparesis on this affected person inhabitants differ from present tips?
Dr Bono: Reglan (metoclopramide). No.
Dr. Yusupov: Sufferers must be recommended to eat smaller meals, keep away from meals with excessive fats content material, in addition to keep away from consuming near their bedtime. GLP-1 agonist dose shouldn’t be elevated except sufferers can tolerate the medicine with out vital GI unwanted side effects. The method to gastroparesis administration on this affected person inhabitants is much like present tips. [The] GLP-1 agonist must be stopped attributable to its impact on motility. The usage of prokinetic drugs (metoclopramide) is off-label in sufferers with out diabetes. Ondansetron may be tried (off-label) to handle nausea and vomiting attributable to gastroparesis.
For physicians with sufferers newly on GLP-1 receptor agonists, particularly semaglutide for weight administration, what are essential counseling factors for the affected person?
Dr Bono: Semaglutide is a peptide that works by mimicking a hormone referred to as glucagon-like peptide 1 (GLP-1), which targets an space of the mind that regulates urge for food and meals consumption. Semaglutide should be taken persistently to see long-term weight reduction results. As quickly as somebody stops taking the drug, their physique fats and former urge for food are likely to return. The analogy may be much like somebody having hypertension — you’re taking the medicine for all times.
Dr. Yusupov: Sufferers must be recommended that GLP-1 agonists sluggish abdomen emptying and reduce urge for food. They need to additionally learn methods to make particular vitamin modifications, in addition to what to anticipate when initiating the therapy or rising the dose. It’s essential to advise sufferers to drink loads of water (I like to recommend 64 oz of water a day). Along with GI results of this medicine class and methods to stop or decrease these results, sufferers must be knowledgeable of the potential danger of thyroid C-cell tumors and suggested to report voice modifications, painful or tough swallowing, or neck lumps.
How can physicians talk to sufferers the severity of gastric signs and when to hunt assist throughout the counseling course of?
Dr Bono: [Explain] that almost all medicine have their dangers and unwanted side effects, and semaglutide is not any completely different. Consideration may be to remain on the identical dose for a number of weeks as an alternative of going up in dose, which may reduce the consequences of the GI signs.
Dr. Yusupov: It is very important counsel sufferers to name their doctor in the event that they develop vomiting or stomach ache, fatigue, persistent diarrhea, or constipation. We positively need to hear again from our sufferers if they’re experiencing vital stomach ache.
- Jensterle M, Ferjan S, Ležaic L, et al. Semaglutide delays 4-hour gastric emptying in women with polycystic ovary syndrome and obesity. Diabetes Obes Metab. Printed on-line December 13, 2022. doi:10.1111/dom.14944
- Signs & Causes of Gastroparesis. Nationwide Institute of Diabetes and Digestive and Kidney Ailments. Final up to date January 2018. Accessed September 6, 2023. https://www.niddk.nih.gov/health-information/digestive-diseases/gastroparesis/symptoms-causes
- [ PubMed ][ Cross Ref ]42. Nuvvula S, Rau P, Belkin D, Houghton JM. Resolution of gastroparesis symptoms with the removal of a dipeptidyl peptidase-4 inhibitor. Am J Gastroenterol. 2021;116:S1289. doi:10.14309/01.ajg.0000786032.36253.51
- Goodman B. They took blockbuster medicine for weight reduction and diabetes. Now their stomachs are paralyzed. CNN. Printed July 25, 2023. Up to date August 29, 2023. Accessed September 6, 2023. https://www.cnn.com/2023/07/25/health/weight-loss-diabetes-drugs-gastroparesis/index.html
- Shapero J. Ozempic, Mounjaro producers sued over danger of abdomen paralysis. The Hill. Printed on-line August 2, 2023. Accessed September 6, 2023. https://thehill.com/policy/healthcare/4134614-ozempic-mounjaro-sued-stomach-paralysis/
|That is the second article in a 2-part sequence on gastroparesis. The primary article What We Know About Semaglutide Adversarial Occasions and Gastroparesis: Half I is accessible here.
This text initially appeared on Gastroenterology Advisor