Gastric dumping syndrome medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Umar Ahmad, M.D.[2]

Overview

The main therapy for the management of dumping syndrome includes diet and pharmacological intervention.

Approach to Management

The following algorithm demonstrates the course of action in the approach of the management of dumping syndrome:

Gastric or Esophageal Surgery

Early dumping symptoms

Late dumping symptoms

Diagnosis

Measure Glucose

Confirm diagnosis with OGTT

Dietary modifications

Dietary supplements

Acarbose

Treatment

Somatostatin analogues

Treatment refractory dumping syndrome

Surgical re-intervention or Continuous enteral feeding

Medical Therapy

Medical therapy for dumping syndrome includes diet and drug therapy.

Level of evidence	Type of evidence
I	Evidence from meta-analysis of multiple, well-designed, controlled studies (randomized trials with low false-positive and low false-negative errors)
II	Evidence from at least 1 well-designed, quasi-experimental study (randomized trials with high false-positive and high false-negative errors)
III	Evidence from well-designed, quasi-experimental studies (nonrandomized, controlled, single-group, pre–post, cohort and time or matched case–control series)
IV	Evidence from well-designed, non-experimental studies (comparative and correlational descriptive and case studies)
V	Evidence from case reports
Grade of recommendation	Level of evidence
A	Level I evidence or consistent findings from multiple studies (level II, III or IV)
B	Level II, III or IV evidence with generally consistent findings
C	Level II, III or IV evidence with inconsistent findings
D	Little or no systematic empirical evidence

Diet

Dietary Modifications (Level III; Grade B)

• Decrease carbohydrate intake
  • Avoid simple sugars like soda, candy sweets, and cookies
• Fluid restriction
  • Wait at least 30 minutes after a meal before drinking
• Increase protein intake
• Increase fat intake
• Increase fiber intake
• Dairy and dairy product restriction
• Shorter meals
• Eat slowly
• Chew properly
• Lying supine for 30 minutes after a meal
• Glycemic index education of foods is important

Dietary Supplements (Level III; Grade C)

The following work similarly to each other. These supplements increase viscosity which in turn decreases gastric emptying and causes a delay in glucose absorption.

• Delay glucose absorption:
  • Pectin
    • 15 grams of Pectin is effective
  • Guar gum
    • 15 grams of Guar gum is effective
  • Glucomannan
    • Glucomannan improves glucose tolerance but isn't as effective
• The increased fiber in the supplements leads to gas and bloating. This decreases tolerability and in turn reduces compliance.

Dietary Foods

The following is a table that illustrates the types of food to take and avoid in the case of dumping syndrome.

Breads, Cereals, Rice and Pasta	Foods To Choose	Foods to Avoid
6-11 servings each day One serving equals: 1 slice bread, 1 cup ready-to-eat cereal 1/2 cup cooked cereal, rice, or pasta	Breads, bagels, rolls, unsweetened cereals, pasta, potatoes, rice, crackers, and soup (only if taken one hour after solid foods at medium temperature).	Sweet rolls and doughnuts Sweetened cereals Pancakes and waffles with syrup Soup (taken with solid foods)
Fruits	Foods to Choose	Foods To Avoid
2-4 servings each day One serving equals: 1 medium size fresh, 1/2 cup canned, 3/4 cup juice	All fresh fruit Drained, unsweetened canned fruit Unsweetened frozen fruit 100 percent pure juice (taken one hour after meals)	Canned fruits in heavy syrup Sweetened frozen fruit Sweetened juice (that is, punch or sports drinks) Candied fruit
Milk and Dairy Products	Foods To Choose	Foods to Avoid
Limit to 2 servings each day One serving equals: 1 cup milk or yogurt	Plain or unsweetened yogurt Skim, 2 percent, or whole milk (taken one hour after meals)	Milkshakes and chocolate milk Sweetened yogurt
Meats, Poultry, Fish, Dry Beans, Peas, Eggs and Cheese	Foods to Choose	Foods to Avoid
2-3 servings or a total of six ounces daily One serving equals: 2-3 ounces cooked meat, chicken, or fish (about the size of a deck of cards) or 1/2 to 3/4 cup cottage cheese or tuna fish or one egg, 1/2 cup cooked beans, two tablespoons peanut butter, or one ounce of cheese. Choose leaner cuts of beef and meat and limit the amount of high-fat items like eggs and cheese.	All meat, fish, poultry, peanut butter, cheese, eggs, and dried beans or legumes	Any not tolerated
Vegetables	Foods to Choose	Foods to Avoid
3-5 servings each day One serving equals: 1 cup raw, 1/2 cup cooked or chopped.	All vegetables	Any not tolerated
Fats, Condiments and Beverages	Foods to Choose	Foods to Avoid
	All butter, margarine, cream, oil, and salad dressings Salt, herbs, spices, and condiments Any sugar-free beverage (coffee, tea, diet soda, etc., taken one hour after solids)	Sweet pickles or relish Sweetened drinks (regular lemonade, soda) Any others not tolerated
Snacks, Sweets, and Desserts	Foods to Choose	Foods to Avoid
	Sugar-free gelatin Sugar-free pudding Sugar-free candy Sugar substitutes	Sugar Candy and chocolate Cakes and cookies Ice cream and sherbet Honey, syrup, and jelly Sugar alcohols such as sorbitol, xylitol, and mannitol

Drug Therapy

Although there are no FDA approved medications specific for dumping syndrome the following pharmacological interventions are used off-label:

• Acarbose (Glucobay, Precose, Prandase)
• Somatostatin analogues such as Octreotide (Sandostatin)

	Acarbose (Level III; Grade B)	Octreotide (Level II; Grade A)
Use	Late dumping syndrome	Early and Late dumping syndrome
Mechanism of Action	Inhibits carbohydrate absorption	Strong inhibitor of the gut hormones (especially insulin)
Dose	Rebound hypoglycemia: 25 mg before breakfast, lunch and dinner Initiate effect: 50 mg daily (QD) For complete resolution of symptoms: 50/100 mg three times daily (TID). Especially beneficial in diabetics with dumping syndrome	Initiate effect: 25-50 μg S.C two-three times daily (BID or TID) Maximum effect: 100-200 μg S.C two-three times daily (BID or TID) Long-acting (New) I.M once monthly
Effect	Decrease postprandial hyperglycemia Decrease postprandial hypotension Decrease gastric emptying Increase insulin secretion	Decrease symptoms Improves Sigstad's score Inhibits vasodilation Decrease insulin levels Decrease gastric emptying Inhibits splanchnic vasoconstriction
Additional information	Limited to diarrhea severity Therapy role not yet clarified	Good for long-term refractory dumping syndrome Side effects are the reason for stopping long-term therapy. Treat this by giving an extra dose before sleeping or a pancreatic enzyme replacement. Short-acting improves symptoms New long-acting release is effective, increases weight and improves the quality of life Safe Last resort drug

Somatostatin analogues

• Pasireotide has a higher receptor affinity than octreotide and is more effective but it does not reduce dumping syndrome symptoms as well as octreotide.
• Even though pasireotide has been safe and effective no results of its clinical trials have been published to date.
  

Drug summary

Drug	Dose	Effect
Tolbutamide	0.25-0.75 g, TID	Subjective improvement
Propranolol	10 mg, QID	Reduced early dumping
Cyproheptadine	4-8 mg, TID	Preventing vasomotor symptoms
Methysergide maleate	4-8 mg, TID	Reduced vasomotor symptoms
Verapamil	120-240 mg, QD	Reduced vasomotor symptoms
Acarbose	50-100 mg, TID	Reduced late dumping
Octreotide	25-100 mcg, TID	Reduced vasomotor symptoms
Pantoprazole (PPI)		Subjective improvement
Cholestyramine		Subjective improvement
Diazoxide	75-260 mg, QD	Subjective improvement
Nifedipine	30 mg, QD	Reduced hypoglycemic symptoms
Exendin 9-39	7500 pmol/kg prime	Reduced hypoglycemic symptoms

Effects of surgery on medications

• After RYGB surgery, bioavailability is decreased in drugs such as:
  • Amoxicillin
  • Azithromycin
  • Cyclosporine A
  • Levothyroxine
  • Nitrofurantoin
  • Mycophenolic acid
  • Phenytoin, phenobarbital
  • Sirolimus
  • Tacrolimus
  • Tamoxifen
• Surgeries that decrease the stomach size may increase toxicity of:
  • Nonsteroidal anti-inflammatory drugs
  • Salicylates
  • Oral bisphosphonates
  • Oral iron
• Any procedure that leads to dumping syndrome will:
  • Increases gut transit time
  • Decease drug absorption