From the Guidelines
Metoclopramide should be discontinued and replaced with a safer alternative, such as domperidone (10mg three times daily), due to the risk of tremors and other movement disorders with prolonged use. According to the most recent study 1, domperidone has fewer central nervous system side effects compared to metoclopramide. Other alternatives include erythromycin (250mg three times daily), which works as a motilin receptor agonist, and ondansetron (4-8mg three times daily), which may help with nausea without movement disorder risks.
For patients with gastroparesis, non-pharmacological approaches like dietary modifications (smaller, more frequent meals, low-fat and low-fiber diet) can also be effective. Additionally, neurokinin-1 (NK-1) receptor antagonists, such as aprepitant, have shown promise in improving nausea and vomiting in patients with gastroparesis 1. It is essential to consult with a healthcare provider before making any medication changes and to taper metoclopramide gradually to avoid abrupt withdrawal.
Some key points to consider when choosing an alternative to metoclopramide include:
- The risk of cardiac side effects with domperidone, which may require dose adjustments or avoidance in certain patients 1
- The potential for tachyphylaxis with erythromycin, limiting its use to short-term treatment 1
- The efficacy of ondansetron in reducing nausea and vomiting, with a recommended dose of 4-8mg three times daily 1
- The importance of individualizing treatment based on the patient's specific needs and medical history.
Overall, the goal is to prioritize the patient's morbidity, mortality, and quality of life when selecting an alternative to metoclopramide, and to choose the safest and most effective treatment option available.
From the FDA Drug Label
Treatment with metoclopramide can cause tardive dyskinesia (TD), a potentially irreversible and disfiguring disorder characterized by involuntary movements of the face, tongue, or extremities. The risk of tardive dyskinesia increases with the duration of treatment and the total cumulative dose Parkinsonian-like symptoms, including bradykinesia, tremor, cogwheel rigidity, or mask-like facies, have occurred, more commonly within the first 6 months after beginning treatment with metoclopramide, but occasionally after longer periods.
The use of metoclopramide can cause tremor and other extrapyramidal symptoms.
- Safer alternatives are not explicitly mentioned in the label for patients experiencing tremor due to metoclopramide use.
- The label recommends discontinuing metoclopramide in patients who develop signs or symptoms of tardive dyskinesia or parkinsonian-like symptoms. 2
From the Research
Prolonged Use of Metoclopramide and Tremor
- Prolonged use of metoclopramide can cause extrapyramidal movement disorders, including tremor, due to its dopamine-2 receptor antagonist properties 3.
- The risk of extrapyramidal side effects, such as tremor, is higher in elderly patients, which may be due to an age-related decrease in the activity of P-gp at the blood-brain barrier 4.
Safer Alternatives to Metoclopramide
- Continuous intravenous infusion of metoclopramide may be a safer alternative to bolus infusion, as it has been shown to reduce the appearance of extrapyramidal side effects, including tremor 5.
- However, there is no clear evidence to suggest a specific alternative medication to metoclopramide that is completely safe from extrapyramidal side effects.
Management of Metoclopramide-Induced Tremor
- Recognition of metoclopramide-induced movement disorders, including tremor, is crucial for prompt treatment and prevention of persistent and disabling conditions 3, 6.
- Clinicians should be aware of the potential neurologic reactions associated with metoclopramide and take measures to reduce the incidence and facilitate treatment of these conditions 6.