What is the recommended dosage of Reglan (metoclopramide) for pregnant women?

Recommended Dosage of Metoclopramide (Reglan) for Pregnant Women

The recommended dosage of metoclopramide (Reglan) for pregnant women with nausea and vomiting is 10 mg orally three times daily before meals.

Indications and Safety Profile

Metoclopramide is commonly used as an adjunctive therapy for nausea and vomiting during pregnancy, particularly when first-line treatments are insufficient. The medication has been extensively studied in pregnancy with reassuring safety data:

• A large register-based cohort study of over 28,000 women exposed to metoclopramide in the first trimester found no increased risk of major congenital malformations, spontaneous abortion, or stillbirth 1
• Metoclopramide has not been associated with teratogenic effects or adverse fetal outcomes when used at recommended doses 2

Dosing Recommendations

For nausea and vomiting in pregnancy (NVP) or hyperemesis gravidarum:

• Standard oral dosing: 10 mg three times daily before meals
• Maximum daily dose: Should not exceed 30 mg per day
• Duration: Use for the shortest time necessary to control symptoms
• Administration timing: Best taken 30 minutes before meals

For severe cases requiring intravenous administration (hospitalized patients):

• 10 mg IV every 8 hours 3

Clinical Considerations

Efficacy

• Metoclopramide has demonstrated similar efficacy to other antiemetics like promethazine for hyperemesis gravidarum 3
• It is considered a second-line agent after pyridoxine (vitamin B6) with or without doxylamine according to the American Gastroenterological Association guidelines 4

Adverse Effects

• Compared to promethazine, metoclopramide has a more favorable side effect profile with:
  • Less drowsiness (58.6% vs 83.6%)
  • Less dizziness (34.3% vs 71.2%)
  • Lower risk of dystonia (5.7% vs 19.2%) 3

Monitoring

• Monitor for extrapyramidal symptoms (acute dystonic reactions, akathisia)
• If extrapyramidal symptoms occur, the medication should be discontinued 4
• Long-term use (>12 weeks) should be avoided due to risk of tardive dyskinesia

Treatment Algorithm

1. First-line therapy: Try pyridoxine (vitamin B6) with or without doxylamine
2. If inadequate response: Add metoclopramide 10 mg orally three times daily before meals
3. For severe cases requiring hospitalization: Consider IV metoclopramide 10 mg every 8 hours
4. If still inadequate: Consider ondansetron as a third-line agent (though with caution in first trimester)
5. For refractory cases: Methylprednisolone may be considered as a last resort

Important Considerations

• Metoclopramide should be used at the lowest effective dose for the shortest duration possible
• The medication crosses the placenta but has not shown evidence of harm to the fetus at recommended doses
• Avoid using in patients with seizure disorders, pheochromocytoma, or history of tardive dyskinesia
• Pregnancy may alter drug metabolism, but standard dosing appears adequate for most women

By following these dosing recommendations and monitoring guidelines, metoclopramide can be safely and effectively used to manage nausea and vomiting during pregnancy when necessary.