title: Immunomodulation for treatment of drug and device refractory gastroparesis.
abstract: OBJECTIVE
  Patients with generalized autoimmune dysautonomia may also present with gastroparesis. Immune dysfunction in such patients can be evaluated using antibodies to glutamic acid decarboxylase (GAD) and full thickness biopsy of stomach. In this study, we utilize immunotherapy for treatment of drug and Gastric Electrical Stimulation (GES) resistant gastroparetic patients with evidence of neuroinflammation on full thickness gastric biopsy and had positive GAD65 autoantibodies.
  
  
  METHODS
  We conducted a retrospective chart review of 11 female patients with drug and device resistant gastroparesis. Patients were treated for a total of 8-12 weeks with either intravenous immunoglobulin (IVIg), or combined mycophenolate mofetil (MM) and methylprednisolone, or only MM. Patients were excluded if they had previous side effects from steroid therapy, low scores on dual-energy X-ray absorptiometry (DEXA) scan results, immune-compromised conditions with infections like tuberculosis and zoster. Symptoms of nausea, vomiting, abdominal pain, early satiety/anorexia, bloating and total symptom score (TSS) as reported by the patients were recorded before and after the treatment at a follow up visit 2 to 16 weeks after initiation of therapy.
  
  
  RESULTS
  Maximum symptom improvement was seen in patients treated with IVIg (67%). 6 patients (55%) had improvement in vomiting, whereas 5 patients (45%) had improvements in nausea, abdominal pain and bloating.
  
  
  CONCLUSIONS
  Immunomodulatory therapy shows positive outcomes in improving vomiting symptom in some gastroparetic patients who have coexisting positive autoimmune profiles. This preliminary data suggests the need for further investigations in immunotherapy targeted to patients with gastroparetic symptoms refractory to approved drug and device therapies.
authors.affiliation: Department of Internal Medicine, Unity Health System, Rochester, NY, United States.
authors.forename: Kaartik
authors.initials: K
authors.lastname: Soota
authors.affiliation: Digestive Diseases, University of Louisville Medical Center, Louisville, KY, United States.
authors.forename: Archana
authors.initials: A
authors.lastname: Kedar
authors.affiliation: Digestive Diseases, University of Mississippi Medical Center, Jackson, MS, United States.
authors.forename: Yana
authors.initials: Y
authors.lastname: Nikitina
authors.affiliation: Digestive Diseases, University of Mississippi Medical Center, Jackson, MS, United States.
authors.forename: Evelyn
authors.initials: E
authors.lastname: Arendale
authors.affiliation: Pediatric Neurology, University of Mississippi Medical Center, Jackson, MS, United States.
authors.forename: Vetta
authors.initials: V
authors.lastname: Vedanarayanan
authors.affiliation: Digestive Diseases, University of Mississippi Medical Center, Jackson, MS, United States; Digestive Diseases, University of Louisville Medical Center, Louisville, KY, United States.
authors.forename: Thomas L
authors.initials: TL
authors.lastname: Abell
keywords: Autoimmune diseases; Autonomic diseases; Gastrointestinal; Neuromuscular disease