Do you avoid the use of GLP-1 R agonist therapy for treatment of obesity in patients with known gastroparesis?

Short answer: yes. Gastroparesis is a well-known side effect of GLP-1 RA therapy. It is dose-dependent, so some patients may tolerate smaller doses but not the highest ones. A recent head-to-head trial of semaglutide vs tirzepatide in obesity (Aronne et al., PMID 40353578) found similar rates of gastrointestinal side effects but more efficacy for weight loss with tirzepatide. Given this, I have, in general, avoided this class of drugs in patients with bothersome gastroparesis, both for the management of diabetes and obesity. However, in cases in which the gastroparesis is mild and the obesity is not responding to lifestyle changes, I would consider trying low-dose tirzepatide with extra counseling about the onset of worsening of gastropares...