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Navigating Opportunities and Obstacles in Gastroparesis, With Ronen Arai, MD
Arai breaks down key recommendations from the 2025 AGA gastroparesis guidelines and what they mean for the field at large.
Gastroparesis, a chronic condition characterized by delayed gastric emptying, continues to place substantial strain on patients and healthcare systems. Following decades of inconsistent diagnostic approaches, scarce therapeutic choices, and mixed research findings, the American Gastroenterological Association (AGA) has introduced new guidelines designed to streamline management and highlight the significant evidence gaps that still need to be addressed.
Despite decades of clinical experience with the condition, the field continues to grapple with inconsistent diagnostic practices, limited therapeutic options, and a lack of high-quality data to guide care. The latest document offers 12 conditional recommendations for the diagnosis and management of gastroparesis, 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.
“I think one of the biggest issues is simply the diagnosis of gastroparesis, which can vary based on center or based on region of the country,” Ronen Arai, MD, a gastroenterologist with Baptist Health South Florida, said to HCPLive. “That's a challenge, because it's hard to come up with a diagnosis that you can do studies on and be talking apples to apples and not have other diseases that you're throwing in there because the diagnosis was improperly made.”
Therapeutic limitations represent another major gap, with just 1 FDA-approved medication, metoclopramide, available. In the new guideline, the AGA conditionally recommends use of metoclopramide as well as erythromycin for first-line gastroparesis treatment.
“As a gastroenterologist being in practice for 25 years, those were around 25 years ago,” Arai said. “There's been a lot of other therapies that have come out, and they mentioned those in the guidelines, but none of them are really recommended as first-line treatment. It's frustrating that we haven't had any therapies that have been studied enough to warrant FDA approval.”
Among these mentioned therapies are domperidone, prucalopride, aprepitant, nortriptyline, buspirone, and cannabidiol, all of which are recommended against as first-line treatment for gastroparesis. Despite this, Arai notes that the guidelines open the door for shared decision making and potential use of these therapies in certain clinical situations.
The guidelines also address advanced interventions. While endoscopic options like G-POEM and certain surgical approaches are not recommended initially, they serve as important considerations for patients who fail medical management. Their inclusion provides clinicians with an updated framework for escalation of care, as these procedures were not mentioned in previous guidelines.
Ultimately, Arai emphasized the need for better-designed clinical trials using standardized diagnostic criteria. Improved consistency in diagnosing gastroparesis could strengthen future research, support therapeutic development, and expand meaningful options for patients living with this burdensome condition.
Editors’ note: Arai reports no relevant disclosures.
