From the Guidelines
Metoclopramide (Reglan) is a prokinetic agent that should be reserved for severe cases of ileus in outpatient settings, due to its potential for serious adverse effects, and its use should not exceed 12 weeks as recommended by the FDA 1. For outpatient management of ileus, the primary approaches include:
- Supportive care: Encourage ambulation, maintain hydration, and use gentle laxatives if appropriate.
- Addressing underlying causes: Treat any contributing factors like electrolyte imbalances or medications that may be slowing gut motility.
- Prokinetic agents: Medications like metoclopramide (10 mg orally or IV three times daily) or erythromycin (250 mg orally or IV four times daily) may be prescribed to stimulate gut motility, with metoclopramide being the only FDA-approved prokinetic agent for the treatment of gastroparesis 1.
- Pain management: Use non-opioid pain relievers when possible, as opioids can worsen ileus.
- Close monitoring: Follow up regularly to assess improvement and adjust treatment as needed. The mechanism of action of metoclopramide involves enhancing upper gastrointestinal motility by increasing the tone of the lower esophageal sphincter, and accelerating gastric emptying, which can help alleviate symptoms of ileus 1. However, its use is limited by the risk of serious adverse effects, such as extrapyramidal signs, including acute dystonic reactions, drug-induced parkinsonism, akathisia, and tardive dyskinesia, which is why it should be used with caution and only in severe cases that are unresponsive to other therapies 1.
From the FDA Drug Label
Metoclopramide stimulates motility of the upper gastrointestinal tract without stimulating gastric, biliary, or pancreatic secretions. Its mode of action is unclear. It seems to sensitize tissues to the action of acetylcholine. Metoclopramide increases the tone and amplitude of gastric (especially antral) contractions, relaxes the pyloric sphincter and the duodenal bulb, and increases peristalsis of the duodenum and jejunum resulting in accelerated gastric emptying and intestinal transit.
The mechanism of action of metoclopramide (Reglan) is through stimulation of motility of the upper gastrointestinal tract, which results in accelerated gastric emptying and intestinal transit.
- It increases the tone and amplitude of gastric contractions
- Relaxes the pyloric sphincter and the duodenal bulb
- Increases peristalsis of the duodenum and jejunum However, the FDA drug label does not provide information on the use of metoclopramide in treating ileus in outpatient settings. 2
From the Research
Mechanism of Action of Metoclopramide
- Metoclopramide is a combined cholinergic agonist and dopamine antagonist 3
- It is currently used exclusively for proximal motility dysfunction 3
- Metoclopramide exerts its prokinetic effect by enhancing acetylcholine release in the enteric nervous system and blocking dopamine receptors in the gastrointestinal tract
Use of Metoclopramide in Treating Ileus
- There is no strong evidence to support the use of metoclopramide in treating ileus in outpatient settings 4, 5
- A study found that neither metoclopramide nor erythromycin were effective in expediting the resolution of ileus in adult surgical patients 5
- However, a case report suggests that metoclopramide may be effective in treating vincristine-induced ileus 6
- The use of metoclopramide in treating ileus is not recommended by some guidelines, which instead suggest early enteral nutrition (EEN) as a effective treatment 5
Treatment of Ileus in Outpatient Settings
- Early enteral nutrition (EEN) is recommended as a effective treatment for ileus in adult surgical patients 5
- Other treatments such as stimulation of ambulation and stop of opioids are also recommended 7
- There is no consensus on the use of metoclopramide or other prokinetic agents in treating ileus in outpatient settings 4, 5, 7