Gastroparesis is a motility disorder characterized by delayed gastric emptying without a mechanical obstruction. Patients often complain of nausea, vomiting, and early satiety. Dietary changes are usually recommended before pharmacologic treatment is considered. Medications for the treatment of gastroparesis are quite limited with only one drug currently approved by the U.S. Food and Drug Administration (FDA), metoclopramide.
The American Gastroenterological Association (AGA) released its newest clinical practice guideline for the management of gastroparesis in September 2025. In this side-by-side comparison, we compare the AGA’s latest clinical practice guideline with the most recent guideline from the American College of Gastroenterology (ACG) on gastroparesis. The recommendations made by these societies are meant to guide clinical practice, taking into consideration the unique desires and needs of individual patients.
This article focuses on pharmacologic treatment recommendations for gastroparesis. We encourage you to review the full guidelines found at the links below for more information on evaluation, as well as, other management strategies for gastroparesis.
Guidelines for Comparison
| Item | ACG Clinical Guideline: Gastroparesis | AGA Clinical Practice Guideline on Management of Gastroparesis |
|---|---|---|
| Authoring Organization | American College of Gastroenterology | American Gastroenterological Association |
| Publication Date | August 2022 | September 2025 |
| Graded Recommendations | Yes | Yes |
| Uses GRADE | Yes | Yes |
| Links | Summary / Full Text | Summary / Full Text |
Key Takeaways
Now to take a look at the similarities and differences in the pharmacologic treatment recommendations for gastroparesis made by these two societies.
Metaclopramide:
- Metaclopramide is suggested by both the ACG and the AGA to treat symptoms of gastroparesis.
Erythromycin:
- Erythromycin is suggested for the treatment of gastroparesis by the AGA, but is not directly addressed by the ACG.
- Erythromycin has a gastric prokinetic effect, but is best used short-term due to the risk of tachyphylaxis; this can be accomplished with drug holidays.
Domperidone:
- Domperidone is not suggested as a first line agent for gastroparesis by the AGA and is not FDA approved for human use in the United States.
- It requires approval as an investigational new drug to be used. The ACG suggests those who are approved may use domperidone, however the medication is no longer available in the United States from the supplier.
5-HT4 Agonists:
- The ACG suggests that 5-HT4 agonists be offered to improve gastroparesis symptoms.
- The AGA suggests that these drugs not be used as a first-line treatment but suggests that prucalopride may be considered for patients with concomitant chronic idiopathic constipation.
Antiemetics:
- Antiemetics are suggested by the ACG for symptom management.
- The AGA suggests against the use of aprepitant in particular as a first-line therapy, but recognizes that it may be helpful for patients with nausea and vomiting that did not respond to treatment with 5HT3 receptor antagonists and other antiemetics.
Central Acting Neuromodulators:
- Central acting neuromodulators are not recommended for patients with gastroparesis by the ACG.
- The AGA does not suggest these medications as first-line therapy, but recognizes that for some patients it may be appropriate to consider them. Patients with co-occurring GI conditions that cause pain or pain from gastroparesis may benefit from TCAs. TCAs with fewer anticholinergic effects, like nortriptyline are preferred in these cases.
- The AGA suggests that buspirone not be used as a first-line treatment, but when it is considered for use it primarily helps with symptoms of early satiety and bloating.
- The use of haloperidol for gastroparesis is not supported according to the ACG and is not directly addressed by the AGA.
Cannabidiol:
- According to the AGA use of cannabidiol is not available for gastroparesis and should only be used in the context of a clinical trial. This was not addressed by the ACG.
Botulinum Toxin:
- Injection of botulinum toxin is not recommended for gastroparesis by the ACG or the AGA.
Gherlin Agonists:
- Use of Gherlin agonists for gastroparesis is not supported according to the ACG and is not addressed by the AGA.
Comparison of Pharmacotherapy Recommendations
| Recommendation | ACG | AGA |
|---|---|---|
| Metoclopramide | In patients with gastroparesis (GP), we suggest treatment with metoclopramide over no treatment for management of refractory symptoms. | In individuals with gastroparesis, the AGA suggests using metoclopramide. |
| Erythromycin | No recommendation made, but the ACG does make note of erythromycin being used in the short-term. | In individuals with gastroparesis, the AGA suggests using erythromycin. |
| Domperidone | In patients with GP where domperidone is approved, we suggest use of domperidone for symptom management. | In individuals with gastroparesis, the AGA suggests against use of domperidone as a first-line treatment. |
| 5-HT4 Agonists | In patients with GP, we suggest use of 5-HT4 agonists over no treatment to improve gastric emptying (GE). | In individuals with gastroparesis, the AGA suggests against the use of prucalopride as a first-line treatment. |
| Antiemetic | In patients with GP, use of antiemetic agents is suggested for improved symptom control; however, these medications do not improve GE. | In individuals with gastroparesis, the AGA suggests against the use of aprepitant as a first-line treatment. |
| Neuromodulators | Central neuromodulators are not recommended for management of GP. | In patients with gastroparesis, the AGA suggests against the use of nortriptyline as a first-line treatment. |
| Buspirone | Not addressed. | In patients with gastroparesis, the AGA suggests against the use of buspirone as a first-line treatment. |
| Haloperidol | Current data do NOT support the use of haloperidol for treatment of GP. | Not addressed. |
| Cannabidiol | Not addressed. | In individuals with gastroparesis, the AGA suggests against the use of cannabidiol (CBD) except in the context of a clinical trial. |
| Botulinum Toxin | Intrapyloric injection of botulinum toxin is not recommended for patients with GP based on randomized, controlled trials. | In patients with gastroparesis refractory to medical management, the AGA suggests against the routine use of pyloric botulinum toxin injection (BTI). |
| Ghrelin Agonists | Current data do NOT support the use of ghrelin agonists for management of GP. | Not addressed. |
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