What is the recommended dose of Reglan (metoclopramide) for treating ileus?

Metoclopramide Dosing for Ileus

For ileus treatment, metoclopramide should be administered at 10-20 mg IV every 6 hours, with consideration for using a prokinetic agent in cases of persistent ileus at a dose of 10 mg PO QID. 1

Dosing Recommendations

Standard Dosing

• Intravenous administration: 10 mg IV slowly over 1-2 minutes, every 6 hours 2
• Oral administration: 10 mg PO QID (for less severe cases or after IV therapy) 1
• Duration: Treatment may be required for up to 10 days before symptoms subside 2

Special Populations

• Renal impairment: For patients with creatinine clearance below 40 mL/min, start at approximately half the recommended dosage 2
• Hepatic impairment: No dose adjustment needed for patients with advanced liver disease if renal function is normal 2

Clinical Evidence and Efficacy

Metoclopramide works by increasing gastrointestinal motility and has shown efficacy in treating ileus in several clinical scenarios:

• In patients with prolonged ileus after spinal cord injury, metoclopramide has been effective when other treatments failed 3
• For postoperative ileus, metoclopramide has demonstrated ability to reverse decreased gastrointestinal myoelectric activity and motility 4
• In a study of patients undergoing gastrectomy with intraperitoneal chemotherapy, metoclopramide significantly reduced the time to tolerate oral intake compared to controls (7.21±1.92 days vs 10.15±2.17 days, p<0.05) 5
• Metoclopramide has shown effectiveness in treating vincristine-induced ileus, with bowel movement resuming within 24 hours of administration 6

Important Considerations and Precautions

Administration Guidelines

• Administer IV doses slowly over 1-2 minutes to minimize side effects 2
• For persistent ileus, consider combining with other treatments such as:
  • Glycerine suppositories
  • Mineral oil retention enemas
  • Bisacodyl 1

Potential Side Effects

• Extrapyramidal symptoms (acute dystonic reactions)
• Drowsiness and sedation
• Diarrhea
• Restlessness

Important Cautions

1. Avoid prolonged use: Extended treatment increases risk of tardive dyskinesia
2. Monitor closely: Especially elderly patients who are more susceptible to side effects
3. Contraindications: Gastrointestinal obstruction, hemorrhage, or perforation

Treatment Algorithm

1. Confirm diagnosis of ileus (absence of bowel sounds, abdominal distension, absence of flatus)
2. Rule out mechanical obstruction before initiating therapy
3. Initial treatment:
   • Start with metoclopramide 10 mg IV every 6 hours
   • If severe symptoms persist, increase to 20 mg IV every 6 hours
4. Monitoring response:
   • Assess for return of bowel sounds and passage of flatus
   • Monitor for side effects, particularly extrapyramidal symptoms
5. Transition to oral therapy:
   • Once improvement is noted, transition to oral metoclopramide 10 mg QID
6. Duration:
   • Continue until resolution of ileus (typically 3-10 days)
   • Discontinue if no response after 48-72 hours

Alternative Approaches

While metoclopramide is commonly used, a systematic review by the Eastern Association for the Surgery of Trauma found limited evidence supporting its efficacy in postoperative ileus compared to early enteral nutrition 7. Consider combining metoclopramide with other approaches for optimal results.