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Breaking Down New AGA Gastroparesis Guidelines, With Kyle Staller, MD, MPH
Staller describes key takeaways from the 12 conditional recommendations made in the American Gastroenterological Association’s new gastroparesis guideline.
Gastroparesis, a chronic disorder of delayed gastric emptying, imposes heavy patient and healthcare burdens. Long hampered by inconsistent diagnoses, limited therapies, and inconclusive data, the field recently gained new guidelines from the American Gastroenterological Association (AGA) aimed at standardizing care while recognizing ongoing evidence gaps.
The document, published in Gastroenterology on September 19, 2025, was developed by an 8-member panel and offers 12 conditional recommendations for the diagnosis and management of the complex gastric motility disorder, including use of 4-hour gastric emptying tests, use of metoclopramide or erythromycin as initial pharmacologic treatment, and shared patient-physician decision making for other treatment recommendations.
For further insight into the key takeaways from this guideline, the editorial team of HCPLive Gastroenterology spoke with guideline author Kyle Staller, MD, MPH, director of the Gastrointestinal Motility Laboratory at Mass General.
Check out part 1 of the interview with Staller here.
“I think one of the reasons that clinical trial data and really clinical experience data has been so disappointing in gastroparesis is a lack of a definition as to what defines gastroparesis,” Staller explained to HCPLive. “Our first statement really concerns, how do we actually do this?”
For individuals with suspected gastroparesis, the AGA guideline includes conditional recommendation against the use of a 2-hour or shorter gastric emptying study compared with a 4-hour gastric emptying study to evaluate for delayed gastric emptying. Staller says this is because in many patients, the diagnosis is either missed or made inappropriately with use of shorter studies.
He goes on to acknowledge the controversy of recommending a longer diagnostic test, which he says requires more resources but is “the key to making a consistent diagnosis.”
Regarding treatment, the guideline conditionally recommends using metoclopramide and erythromycin as first-line therapies, something Staller notes poses another potential source of controversy.
“These drugs are far from perfect, and I don't want people to get the idea that just because they're the only things that we suggest for in this particular [document] means that these are the only things that you'll use, but they are the only things that met our threshold of evidence, this sort of minimal clinically important difference,” he explained. “Those are what we recommend as first line treatment, but we recognize that many patients will fail these for one reason or another, be it side effects or lack of efficacy, and will need to go on to second line treatments.”
In the guideline, the AGA issued conditional recommendations against the use of domperidone, prucalopride, aprepitant, nortriptyline, buspirone, and cannabidiol as first-line therapies for gastroparesis, additionally conditionally recommending against the routine initial use of gastric peroral endoscopic pyloromyotomy (G-POEM) or gastric electrical stimulation. No recommendation was given regarding the use of surgical pyloromyotomy and surgical pyloroplasty.
“I [don’t think any] of us would argue that you should be using any of these medications as first line therapy, but in a shared decision making model, a lot of these would be very much useful for second line therapy,” Staller said. “We wanted to say that in the aggregate population that we have, which we've already acknowledged is very heterogeneous, that many patients would benefit from these, but many would not.”
Rather than seeing the guideline and thinking there is no hope for gastroparesis patients based on all of the therapies recommended against as first-line treatment, Staller emphasizes that he wants readers to understand the document’s nuances and recognize the second-line treatment options that exist.
Editors’ Note: Relevant disclosures for Staller include Focus Medical Communications, Retalsis, Anji, and Ardlix.
