From the Guidelines
The first-line prokinetic agents for patients requiring prokinetic therapy are metoclopramide and domperidone. Metoclopramide is typically prescribed at 10 mg three times daily before meals, while domperidone is usually given at 10 mg three to four times daily before meals. Treatment duration should generally be limited to 12 weeks or less due to potential side effects, particularly with metoclopramide which carries a risk of tardive dyskinesia with prolonged use 1. These medications work by antagonizing dopamine D2 receptors, which enhances gastric emptying and improves gastric motility. Metoclopramide also has 5-HT4 agonist properties that contribute to its prokinetic effects. When prescribing these medications, it's essential to monitor for side effects, which can include extrapyramidal symptoms (especially with metoclopramide), headache, and dizziness. Domperidone has a lower risk of crossing the blood-brain barrier, resulting in fewer central nervous system side effects compared to metoclopramide, but it may cause QT prolongation. In patients with renal or hepatic impairment, dose adjustments may be necessary. Second-line options include erythromycin, which works as a motilin receptor agonist, but is generally reserved for cases where first-line agents are ineffective or contraindicated 1.
Some key points to consider when using prokinetic agents include:
- Monitoring for side effects, particularly with metoclopramide, which can cause extrapyramidal symptoms and has a risk of tardive dyskinesia with prolonged use 1
- Limiting treatment duration to 12 weeks or less to minimize the risk of side effects 1
- Adjusting doses in patients with renal or hepatic impairment 1
- Considering second-line options, such as erythromycin, if first-line agents are ineffective or contraindicated 1
- Being aware of the potential for QT prolongation with domperidone and monitoring accordingly 1
It's also important to note that the use of prokinetic agents should be individualized and based on the specific needs and circumstances of each patient. The most recent and highest quality study available should be consulted to inform treatment decisions 1.
From the FDA Drug Label
Metoclopramide The FDA drug label does not answer the question.
From the Research
First-Line Prokinetic Agents
The first-line prokinetic agents for patients requiring prokinetic therapy are:
- Metoclopramide, which is the only currently approved medication for gastroparesis in the United States 2, 3
- Domperidone, a dopamine D2 receptor antagonist, available for prescription through the FDA's program for Expanded Access to Investigational Drugs 2
Other Prokinetic Agents
Other prokinetic agents that may be used include:
- Macrolides, which are used off label and are associated with tachyphylaxis and variable duration of efficacy 2
- Aprepitant, which relieves some symptoms of gastroparesis 2
- Erythromycin, which has been shown to be effective in the treatment of severe gastroparesis in an ambulatory setting 4
- Cisapride, which seems capable of maintaining a gastrokinetic effect under chronic administration 5
Considerations for Prokinetic Therapy
When considering prokinetic therapy, it is essential to balance the benefits and risks of treatment, as prokinetic agents can have potential drug-drug interactions and side effects 6, 2, 3