Mirtazapine treatment of diabetic gastroparesis as a novel method to reduce tube-feed residual: a case report

Abstract

IntroductionGastroparesis is a common motility disorder that is characterized by delayed gastric emptying in the absence of mechanical obstruction. Diabetes, along with other neuromuscular and infiltrating disorders, can predispose individuals to an increased risk of developing gastroparesis. Gastroparesis can be easily diagnosed through gastric emptying studies but is usually difficult to successfully treat. Therapy usually begins with pro-kinetic and anti-emetic agents.Case presentationOur patient was an 87-year-old African-American woman who was a nursing home resident, with a history of diabetes mellitus type 2 and subarachnoid hemorrhage leading to aphasia, hemiplegia, seizures and dysphagia requiring percutaneous gastric feeds. While at the nursing home, she had recurrent aspiration pneumonia and large tube-feed residuals consistent with a diagnosis of underlying gastroparesis. Her management included metoclopramide and reduced tube-feeding rates, which improved her symptoms. However, within months the aspiration and increased residuals returned. After trials of different medication therapies without success, she started mirtazapine and her residual volume and aspirations decreased with a dose of 15mg nightly.ConclusionIn patients with gastroparesis recalcitrant to first line therapies such as metoclopramide, off-label use of mirtazapine may provide adequate non-invasive management of gastroparetic symptoms.

The effect of mirtazapine on gastric accommodation, gastric sensitivity to distention, and nutrient tolerance in healthy subjects

“…This weight gain might be attributable to antagonism of 5‐HT2C receptors, to the activation of H 1 receptors and to the increase in fat mass by elevated leptin levels . Mirtazapine also seems to enhance gastrointestinal transit, and in some case reports, it was observed that mirtazapine improved symptoms of gastroparesis unresponsive to conventional prokinetics . In a recent placebo‐controlled trial in FD patients with weight loss, mirtazapine was shown to improve symptoms, especially early satiation and weight loss, and to enhance nutrient tolerance .…”

Prokinetic effects of mirtazapine on gastrointestinal transit

“…Recently, it was reported that mirtazapine reduced visceral hypersensitivity and accelerated liquid gastric emptying in rats with neonatal colon sensitivity (42). Clinic case report showed that mirtazapine was effective in treating severe gastroparesis unresponsive to the conventional prokinetic treatment (29); in a patient with diabetic gastroparesis who is recalcitrant to first-line treatment, mirtazapine improved gastroparetic symptoms (20). We therefore hypothesized that mirtazapine might have a prokinetic effect on GI motility.…”

Current advances in treatment of gastroparesis

“…It has been postulated that Mirtazapine agonism of 5-HT 1A receptors may lead to symptom relief in gastroparetics with symptoms refractory to other agents, but there is a paucity of data looking at this potential therapeutic use. Studies in dogs have shown that Mirtazapine can accelerate gastric emptying [89] and four reported human case reports have shown rapid and dramatic improvement or resolution of symptoms in patients previously refractory to extensive medical regimens [90][91][92].…”