Prokinetics in the Treatment of Diabetic Gastroparesis

Clinical Manifestations

Diabetic gastroparesis affects both type 1 and type 2 diabetics; it concerns up to 58% of patients with diabetes. The disorder is mainly contributed to by diabetes-related autonomic neuropathy, damage to the interstitial cells of Cajal and smooth muscle cells, oxidative stress, and acute hyperglycemia. The occurrence of gastropathy is more frequent in patients who have at least one other diabetic complication. Women are more commonly affected. 

Symptoms of stomach emptying disorders include a feeling of fullness, pressure in the epigastrium, early satiety, and vomiting after meals. A consequence of gastroparesis can be prolonged postprandial hyperglycemia.

Diagnosis

The gold standard for examining diabetic gastropathy is primarily gastric emptying scintigraphy using labeled solid food, but patients should also undergo gastroscopy to exclude mechanical evacuation obstruction and gastroesophageal reflux. 

Therapy

In the treatment of diabetic gastroparesis, prokinetics are primarily used to improve stomach motility, increase its tone, and speed up emptying. The desired effect is, of course, also relief from gastrointestinal discomfort and maintaining adequate glucose levels. Proton pump inhibitors used alongside do not address gastroparesis itself but play a role in managing concomitant esophageal reflux.

When selecting a medication, it is necessary to avoid preparations that potentially prolong the QT interval on the ECG, as this is associated with sudden death in diabetics. From this perspective, itopride-hydrochloride appears to be the safest and most effective compared to other drugs from the prokinetic group.

Effect of Prokinetics on Diabetes Management

According to the results of a meta-analysis published in September 2019 in Gastroenterology Research and Practice, administered prokinetics may also impact long-term diabetes management. The study included 5 studies with a total of 190 patients. A statistically significant difference was found between the glycated hemoglobin values in patients treated with prokinetics and the control group, which was given a placebo. No difference was found in fasting blood glucose and serum insulin levels between these two groups, but given that fasting blood glucose assessment has its limitations, glycated hemoglobin appears to be a better indicator of the beneficial effect of prokinetics on diabetes management. 

Conclusion

Diabetic gastroparesis is a common complication of diabetes mellitus, which is poorly tolerated by patients, negatively impacts subjective health perception and mental state, and leads to prolonged hyperglycemic states. Due to their good tolerability and relatively few side effects and drug interactions, prokinetics are a suitable therapeutic agent for addressing this condition. Compared to invasive procedures, treatment is associated with fewer complications and is also more economical. Some studies have shown the positive effect of prokinetics not only on improving gastrointestinal motility and accelerating stomach emptying but also on improving diabetes management in terms of reducing glycated hemoglobin. Itopride appears to be the safest prokinetic, as it does not prolong the QT interval, among other things. The effect of prokinetics in the treatment of diabetics is also the subject of further research.

(sobo)

Sources:
1. Kim Y., Chung W. Ch., Lee S. J. A meta-analysis of the efficacy of prokinetic agents against glycemic control. Gastroenterol Res Pract 2019; 2019: 3014973, doi: 10.1155/2019/3014973.
2. Keil R., Perušičová J. Diabetic Gastroparesis − How often do we think about this complication of diabetes? Diabetology, Metabolism, Endocrinology, Nutrition 2003; 6 (2): 79−82.