From the Guidelines
Management of a metoclopramide (Reglan) reaction involves immediate discontinuation of the medication and administration of diphenhydramine (Benadryl) 25-50 mg IV or IM to reverse acute dystonic reactions. For severe extrapyramidal symptoms, benztropine (Cogentin) 1-2 mg IM or IV can be given as an alternative 1. Supportive care should be provided based on symptoms, including monitoring vital signs and ensuring adequate hydration. For patients experiencing akathisia (restlessness), benzodiazepines such as lorazepam 1-2 mg may provide relief. These interventions work by blocking dopamine receptors or providing anticholinergic effects to counteract metoclopramide's dopamine-blocking properties. Most acute reactions resolve within 24-48 hours after treatment, though some extrapyramidal symptoms may persist longer. Patients should be counseled to avoid metoclopramide in the future and this should be documented as an adverse drug reaction in their medical record. Those with a history of Parkinson's disease, dystonia, or other movement disorders are at higher risk for these reactions and should generally avoid metoclopramide, as the level of evidence regarding the benefits of metoclopramide for the management of gastroparesis is weak, and given the risk for serious adverse effects, its use in the treatment of gastroparesis beyond 12 weeks is no longer recommended by the FDA 1.
Some key points to consider in the management of metoclopramide reactions include:
- Immediate discontinuation of metoclopramide
- Administration of diphenhydramine or benztropine for acute dystonic reactions
- Supportive care, including monitoring of vital signs and hydration
- Consideration of benzodiazepines for akathisia
- Counseling to avoid metoclopramide in the future
- Documentation of the adverse drug reaction in the medical record.
It's also important to note that metoclopramide should be reserved for severe cases of gastroparesis that are unresponsive to other therapies, due to the risk of serious adverse effects 1.
From the FDA Drug Label
WARNINGS Neuroleptic Malignant Syndrome (NMS) ... The management of NMS should include 1) immediate discontinuation of metoclopramide and other drugs not essential to concurrent therapy, 2) intensive symptomatic treatment and medical monitoring, and 3) treatment of any concomitant serious medical problems for which specific treatments are available Extrapyramidal Symptoms (EPS) Acute Dystonic Reactions ... If these symptoms should occur, inject 50 mg Benadryl (diphenhydramine hydrochloride) intramuscularly, and they usually will subside. Cogentin® (benztropine mesylate), 1 to 2 mg intramuscularly, may also be used to reverse these reactions Tardive Dyskinesia ... Metoclopramide should be discontinued in patients who develop signs or symptoms of TD. Parkinsonian-like Symptoms ... These symptoms generally subside within 2 to 3 months following discontinuance of metoclopramide
The management for a metoclopramide (Reglan) reaction includes:
- Immediate discontinuation of metoclopramide and other non-essential drugs
- Intensive symptomatic treatment and medical monitoring
- Treatment of any concomitant serious medical problems
- For acute dystonic reactions, administration of 50 mg Benadryl (diphenhydramine hydrochloride) intramuscularly or 1 to 2 mg Cogentin® (benztropine mesylate) intramuscularly
- For tardive dyskinesia, discontinuation of metoclopramide
- For parkinsonian-like symptoms, discontinuation of metoclopramide, with symptoms generally subsiding within 2 to 3 months 2
From the Research
Management of Metoclopramide (Reglan) Reaction
The management of a metoclopramide (Reglan) reaction typically involves discontinuation of the drug and administration of anticholinergic agents to control extrapyramidal symptoms.
- Discontinuation of metoclopramide is crucial in managing the reaction, as continued use can worsen symptoms 3, 4.
- Anticholinergic agents, such as biperiden, are effective in controlling acute dystonic reactions caused by metoclopramide 3, 4.
- In some cases, the reaction may be prolonged, lasting up to 53 days, and may require chronic treatment with anticholinergic drugs 4.
Patient Monitoring
It is essential to monitor patients for extrapyramidal side effects, especially those receiving high doses of metoclopramide, as these reactions can be unpredictable and life-threatening 3, 5.
- Patients with a history of metoclopramide-induced dystonic reactions should be cautious when taking the drug, and alternative treatments should be considered 6.
- Children and older patients, especially those with renal failure, are more susceptible to metoclopramide-induced movement disorders and should be closely monitored 5, 7.
Treatment Considerations
The treatment of metoclopramide-induced reactions should take into account the individual patient's sensitivity to the drug and their medical history.