From the Guidelines
Reglan (metoclopramide) should be used with extreme caution in patients with chronic kidney disease stage 4 (CKD 4) due to the increased risk of extrapyramidal symptoms and other adverse effects. The medication is primarily eliminated by the kidneys, and reduced kidney function can lead to drug accumulation, increasing the risk of side effects 1. Although the provided evidence primarily focuses on pain management, it does mention the use of metoclopramide for opioid-related nausea/vomiting, highlighting the need for caution with its use in patients with renal impairment 1.
Key considerations for the use of Reglan in CKD 4 include:
- Reducing the dose by 50% of the normal dose to minimize the risk of accumulation and side effects
- Close monitoring for neurological side effects such as tremors, rigidity, and involuntary movements
- Limiting the duration of therapy to the shortest period necessary, ideally less than 12 weeks, due to the increased risk of tardive dyskinesia with prolonged use
- Considering alternative medications with less renal elimination if appropriate for the patient's condition
- Regular reassessment of kidney function and medication response throughout treatment
It's crucial to weigh the benefits of using Reglan against the potential risks in patients with CKD 4, considering the limited evidence directly addressing its use in this population 1. Given the potential for severe side effects, a cautious approach is warranted, prioritizing the patient's safety and quality of life.
From the FDA Drug Label
Use in Patients with Renal or Hepatic Impairment Since metoclopramide is excreted principally through the kidneys, in those patients whose creatinine clearance is below 40 mL/min, therapy should be initiated at approximately one-half the recommended dosage.
Metoclopramide is known to be substantially excreted by the kidney, and the risk of toxic reactions to this drug may be greater in patients with impaired renal function (see DOSAGE & ADMINISTRATION, Use in Patients with Renal or Hepatic Impairment)
The patient has CKD 4, which means their creatinine clearance is below 40 mL/min, but not exactly specified.
- Dose adjustment is necessary for patients with renal impairment.
- The recommended dose for CKD 4 patients should be approximately one-half the recommended dosage.
- Close monitoring of the patient is necessary to adjust the dosage as needed.
- The use of metoclopramide in patients with severe renal impairment should be cautious due to the increased risk of toxic reactions 2.
From the Research
Reglan in CKD 4
- Reglan, also known as metoclopramide, is a medication used to treat nausea, vomiting, and gastroparesis.
- In patients with chronic kidney disease (CKD) stage 4, the use of metoclopramide requires careful consideration due to the potential risk of adverse events 3.
- CKD stage 4 is characterized by a glomerular filtration rate (GFR) of 15-29 mL/min/1.73 m2, indicating severely impaired kidney function 4.
- The management of CKD involves cardiovascular risk reduction, treatment of albuminuria, avoidance of potential nephrotoxins, and adjustments to drug dosing 4.
- Metoclopramide is a dopamine antagonist that can cause extrapyramidal side effects, such as restlessness, which occurred in 15% of patients treated with metoclopramide in one study 3.
- The use of metoclopramide in patients with CKD stage 4 may require dose adjustments and close monitoring for adverse events, particularly extrapyramidal side effects and cardiovascular events 3.
- Alternative medications, such as domperidone, may be considered for the treatment of gastroparesis in patients with CKD stage 4, although the risk of adverse events, such as QTc prolongation, must be carefully evaluated 5, 3.