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Metoclopramide

Oral
Intravenous
Intramuscular
Intranasal
Class
Antiemetics
Subclass
5-HT3 receptor antagonists
Generic name
Metoclopramide hydrochloride
Brand names
Reglan®
Common formulations
Tablet
Dosage and administration
Adults patients
Gastroparesis in patients with diabetes mellitus • Acute or recurrent
•
Maintenance: 10 mg PO QID for 2-8 weeks, and up to 12 weeks
•
Maximum: 40 mg per day
Taken 30 minutes before each meal and at bedtime. Consider starting at 5 mg QID in elderly patients, titrating to 10 mg QID based on response and tolerability.
GERD • Refractory, continuous dosing
•
Maintenance: 10-15 mg PO QID for 4-12 weeks
•
Maximum: 60 mg per day
Taken 30 minutes before each meal and at bedtime. Consider starting at 5 mg QID in elderly patients, titrating to 10-15 mg QID based on response and tolerability.
Nausea and vomiting in patients with migraine attacks • Off-label
•
10-20 mg PO once
Nausea and vomiting of pregnancy • Off-label
•
5-10 mg PO q6-8h
Indications for use
Labeled indications
Adults
•
Symptomatic relief of GERD (refractory, continuous dosing)
•
Symptomatic relief of gastroparesis in patients with diabetes mellitus (acute or recurrent)
Off-label indications
Adults
•
Symptomatic relief of nausea and vomiting in patients with migraine attacks
•
Symptomatic relief of nausea and vomiting of pregnancy
Safety risks
Boxed warnings
Tardive dyskinesia
•
Maintain a high level of suspicion, as metoclopramide can cause tardive dyskinesia, with risk increasing with treatment duration and total cumulative dosage. Avoid treatment for longer than 12 weeks. Discontinue metoclopramide if signs or symptoms of tardive dyskinesia develop. Do not use meroclopramide in patients with a history of tardive dyskinesia or a dystonic reaction to metoclopramide.
Contraindications
Hypersensitivity to metoclopramide or its components
Epilepsy
Pheochromocytoma
•
Do not use metoclopramide in patients with pheochromocytoma or other catecholamine-releasing paragangliomas.
Situations where stimulation of gastrointestinal motility is dangerous
•
Do not use metoclopramide in situations where stimulating gastrointestinal motility could be dangerous, such as in gastrointestinal hemorrhage, mechanical obstruction, or perforation.
Warnings and precautions
Cognitive difficulties, motor impairment
•
Use extreme caution in patients performing activities requiring mental alertness, such as driving or operating machinery.
Depression, suicidal ideation
•
Maintain a high level of suspicion, as metoclopramide has been associated with depression, suicidal ideation, and suicide in patients with or without a history of depression. Avoid metoclopramide in patients with a history of depression.
Fluid retention
•
Use caution in patients with congestive HF or cirrhosis, as metoclopramide causes a transient increase in plasma aldosterone.
Hypertension
•
Maintain a high level of suspicion, as metoclopramide may elevate BP. Avoid metoclopramide in patients with hypertension or in patients taking MAOIs.
Increased serum metoclopramide levels
•
Use caution in patients taking strong CYP2D6 inhibitors and in CYP2D6 poor metabolizers. Reduce metoclopramide dose to 5 mg QID or 10 mg TID for GERD and 5 mg QID for gastroparesis.
Increased serum prolactin
•
Maintain a high level of suspicion, as metoclopramide elevates prolactin levels, which can cause galactorrhea, amenorrhea, gynecomastia, and impotence.
Neuroleptic malignant syndrome
•
Maintain a high level of suspicion, as metoclopramide may cause neuroleptic malignant syndrome when overdosed or given with another drug associated with the condition. Avoid metoclopramide in patients receiving other drugs associated with neuroleptic malignant syndrome, including typical and atypical antipsychotics.
Parkinsonism
•
Maintain a high level of suspicion, as metoclopramide may cause other extrapyramidal symptoms, in addition to tardive dyskinesia, including parkinsonism and motor restlessness.
Specific populations
Renal impairment
CrCl ≥ 60 mL/min
•
Use acceptable. No dose adjustment required.
CrCl 15-60 mL/min
•
Reduce to 5 mg QID or 10 mg TID for gastroseophageal reflux disease and 5 QID for gastroparesis.
CrCl < 15 mL/min
•
Reduce to 5 mg QID or 10 mg BID for gastroseophageal reflux disease and 5 BID for gastroparesis.
Renal replacement therapy
Any modality
•
Dose as in CrCl < 15 mL/min.
Hepatic impairment
Child-Pugh A (mild)
•
Use acceptable. No dose adjustment required.
Child-Pugh B (moderate)
•
Reduce to 5 mg QID or 10 mg TID for gastroseophageal reflux disease and 5 QID for gastroparesis.
Child-Pugh C (severe)
•
Reduce to 5 mg QID or 10 mg TID for gastroseophageal reflux disease and 5 QID for gastroparesis.
Substantial chronic alcohol consumption
•
Use with caution.
Pregnancy and breastfeeding
Pregnancy
All trimesters • Australia Category: A
•
Generally acceptable for short-term use.
Breastfeeding
Use only if benefits outweigh potential risks.
Low levels in breastfed infants (5-25%).
No overt adverse effects reported in breastfed infants.
No overt adverse effects on lactation reported.
Adverse reactions
Common 1-10%
•
Restlessness, somnolence, fatigue, tardive dyskinesia, parkinsonism, akathisia, extrapyramidal signs, seizure, hallucinations, acute dystonic reactions
Uncommon < 1%
•
Neuroleptic malignant syndrome, serotonin syndrome, insomnia, headache, confusion, nervousness, dizziness, depression, suicidal ideation
Unknown frequency
•
Fluid retention, ↑ serum aldosterone, galactorrhea, gynecomastia, amenorrhea, erectile dysfunction, AV block, hypotension, hypertension, bradycardia, nausea, diarrhea, jaundice, ↑ LFTs, urinary frequency, urinary incontinence, agranulocytosis, ↓ blood neutrophil count, ↓ WBC count, urticaria, bronchospasm, skin rash, angioedema, laryngeal edema, visual disturbances, heart failure, supraventricular tachycardia, methemoglobinemia, sulfhemoglobinemia, porphyria
Interactions
Drug(s)
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