Help with ideas on prokinetics for gastroparesis and advice on Mestinon

[EddieB]

Hi @kangaSue , I went to my doctor and he agreed that mirtazapine would be a good option to try.

How did this go for you?

My gastro had me try mirtazapine last June. I started tapering off of it 2 months ago, as it doesn’t help anymore and may actually have made things worse.

But because of the the dramatic increase of symptoms it caused, tells me that there is something here that can be influenced. I essentially need an opposing drug, if there is such a thing...

 

[kangaSue]

How did this go for you?

My gastro had me try mirtazapine last June. I started tapering off of it 2 months ago, as it doesn’t help anymore and may actually have made things worse.

But because of the the dramatic increase of symptoms it caused, tells me that there is something here that can be influenced. I essentially need an opposing drug, if there is such a thing...

As is the case with many meds for me, I had to stop mirtazapine because of it causing increasing abdominal pain after initially helping significantly to reduce the same symptom.

Were you using mirtazapine at low dose? I see it suggested that 2 different antidepressant class meds used at low dose may have better results, and also have fewer side effects when using them for GI dysmotility issues.
https://www.ncbi.nlm.nih.gov/pubmed/29274869

Some other reading on the subject of pain symptoms
https://www.practicalpainmanagement...se-antidepressants-multimodal-pain-management
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5510574/

 

[EddieB]

As directed by the gastro doc, I tried doses from 3.5mg to 30. 15 had the best success for about 2 months, but then symptoms began to come back. Went up to 22.5 then 30, no help. Decided to taper off, at 5mg now. Doses below 15mg causes horrible side effects.

A previous gastro had me take low dose amitriptyline years ago. Also seemed to help for while, then quit.

Thank you for the links. I’m losing confidence that these meds can work for more than a limited period of time.

 

[kangaSue]

As directed by the gastro doc, I tried doses from 3.5mg to 30. 15 had the best success for about 2 months, but then symptoms began to come back. Went up to 22.5 then 30, no help. Decided to taper off, at 5mg now. Doses below 15mg causes horrible side effects.

That sounds like a typical response to antidepressants for some people trying them for GI dysfunction and pushing up to the higher doses of some of them are known to impair GI motility, hence why some sources suggest adding in another similar or complimentary antidepressant also at low dose.

A previous gastro had me take low dose amitriptyline years ago. Also seemed to help for while, then quit.

I didn't tolerate this one right from the outset, nor nortriptyline (and several others for that matter).

I saw it said by someone here in PR once that milnacipran is the only antidepressant that blocks reuptake of norepinephrine and serotonin in the ratio 3:1, and that this is the natural ratio of the two in the brain. Not tried it myself but have seen the odd mention of it's use in gastroparesis patient studies.

Thank you for the links. I’m losing confidence that these meds can work for more than a limited period of time.

Some lucky ducks have spectacular response to different one's, they're in a big minority though. I did have a spectacular response was to cipromil at low dose, but that only lasted for one week.

 

[EddieB]

Yes, according to the gastro he has had some miraculous results with the mirtazapine. But when it didn’t work he didn’t have any other suggestions, other than I should see a physiatrist for direction. Unfortunate I live in a rural area and there aren’t any, and I’m too sick to travel. And the odds of finding someone that isn’t going to just guess are slim.

From what I’ve researched, I believe I’m low in GABA. This supposedly has a direct action on lower esophagus function. I have horrible reflux that is otherwise unexplainable. I also get severe anxiety attacks, also indicated low GABA.. Sulpiride, Gabapentin or buspirone might help? The motility seems to be improving as I back off the mirtazapine.

I’ve never checked amino acids, I did lab work last week, see if anything shows up deficient. Sure would rather take some supplements than the drugs.

 

[lenora]

Serg1942.....I'm sure you've already thought of this, but thought I'd mention it anyway. What about Ensure to help with your loss of calories and most important, vitamins and minerals. There are very different types, so do be careful. I have gastroparesis, on/off mixed with other problems, and find that I can drink it very slowly over the course of a a.m. and another in the afternoon. Right now, I'm on one with a prebiotic in it. I've found chocolate to taste the best (and I'm not really a chocolate freak). Just do it once/day to begain, slowly and at least you'll be getting some nourishment. Also, watch your electrolytes....I ended up in bad trouble with getting them all scrambled. I'm talking serious, near death, trouble. I'm supposed to be getting tested very 2 wks., but I've put that on hold as Dr's. office hold no attraction for me...especially at this time. I'm trying on my own. You could end up with worse trouble than gastroparesis, so please, please be careful. Yours, Lenora

 

[EddieB]

I use a product from meta genics, pea and rice protein drink. It has good calories and helps keep on weight.

 

[kangaSue]

Yes, according to the gastro he has had some miraculous results with the mirtazapine. But when it didn’t work he didn’t have any other suggestions, other than I should see a physiatrist for direction. Unfortunate I live in a rural area and there aren’t any, and I’m too sick to travel. And the odds of finding someone that isn’t going to just guess are slim.

Even given Psychiatrist's expertise in antidepressant meds, it's still a guessing game as to which one will work best for you and finding the best fit usually only comes about from trial and error.

From what I’ve researched, I believe I’m low in GABA.

I've been looking down the GABA avenue too of late. GABA and glycine powders were a total disaster but taurine has been well tolerated. Taurine can be deficient in both diabetic and idiopathic gastroparesis.

Sulpiride, Gabapentin or buspirone might help?

Impaired gastric accommodation is said to be a symptom of both gastroparesis and Functional Dyspepsia in about 85% of cases and buspirone is one suggested med that can help with that. I take a nitrate myself (nicorandil, for chronic intestinal ischemia) and nitrates are also known to help with this symptom.

(I have evidence of this in a Gastric Emptying Scintigraphy study, food is not seen to sink immediately to the bottom of the stomach (Intragastric meal distribution at time 0 minutes);
https://www.tandfonline.com/doi/abs/10.1080/00365521.2019.1710244 Gastroparesis versus dyspepsia by intragastric meal distribution: new diagnostics and definitions ahead )

Gabapentin didn't help me with abdominal pain but again, nitrates have analgesis properties for both nerve and muscle pains and nicorandil had significant effect. I've heard of sulpiride being helpful for Functional Dyspepsia but not a med available to me locally.

I also get severe anxiety attacks, also indicated low GABA..

An imbalance in your gut bacterial mix can also be a cause of anxiety issues (via the gut-brain axis, and the toxins released by gut bacteria)

 

[EddieB]

I've been looking down the GABA avenue too of late.

I’m also wondering if the mirtazapine was able to balance/increase GABA for little while, then pooped out?

GABA and glycine powders were a total disaster but taurine has been well tolerated.

I tried magnesium glycinate, made me sick. I was recommended taurine, but thought I’d wait until I get the results from the amino acids test. Please tell me how much you take and what it did for you?

 

[kangaSue]

I’m also wondering if the mirtazapine was able to balance/increase GABA for little while, then pooped out?

You see it suggested in various articles that antidepressant treatments may have the ability to increase GABA neurotransmission. I have no idea why that could be just of a short lasting effect.

I was recommended taurine, but thought I’d wait until I get the results from the amino acids test. Please tell me how much you take and what it did for you?

For the first month, it enabled me to re-introduce some foods that I had been having problems but that effect became diminished. However, I found I could better tolerate some liquid nutrition supplements without getting the nausea and/or vomiting they were otherwise causing me and that effect is still holding.

It has also helped me with improved sweating in response to heat so I don't feel so off from sun exposure. It's also significantly reduced my easy bruising and for the first time in 10 years, the backs of my hands aren't black, blue and purple looking.

Having less diarrhea episodes in a day is another additional benefit, something to do with helping bile flow I expect. I have had a lessening in abdominal pain as well so maybe something to do with taurine's anti-inflammatory properties I guess.

I take 1/8 th of a teaspoon of (pharmaceutical grade) taurine powder, 3 x a day, one hour before food to let taurine reach it's maximum level in the body (that's what I read anyway)