Metoclopramide Dosing for Moderate to Severe Ileus
For moderate to severe ileus, metoclopramide should be administered at 10-20 mg IV every 6 hours, with transition to oral therapy at 10 mg four times daily once improvement is noted. 1
Initial Treatment Protocol
IV Administration
- Starting dose: 10 mg IV every 6 hours
- For severe cases: Increase to 20 mg IV every 6 hours if symptoms persist
- Duration: Continue until signs of bowel function return (typically 3-10 days)
- Maximum duration: Discontinue if no response after 48-72 hours
Oral Administration
- Dose: 10 mg PO four times daily
- When to use: After initial IV therapy shows improvement or for less severe cases
- Timing: Approximately 30 minutes before meals and at bedtime
Monitoring Parameters
- Return of bowel sounds
- Passage of flatus
- Resolution of abdominal distension
- Side effects, particularly extrapyramidal symptoms
Important Considerations
Precautions
- Rule out mechanical obstruction before initiating therapy 1
- Avoid prolonged use due to increased risk of tardive dyskinesia 2
- Monitor closely for extrapyramidal side effects, especially in elderly patients 2
- QTc monitoring may be necessary for prolonged use 2
Contraindications
- Gastrointestinal obstruction
- Gastrointestinal hemorrhage
- Gastrointestinal perforation
Adjunctive Treatments
For persistent ileus, consider combining metoclopramide with:
- Glycerine suppositories
- Mineral oil retention enemas
- Bisacodyl 1
Evidence Base
The recommended dosing is supported by clinical guidelines 1 and case reports showing efficacy in various types of ileus, including postoperative ileus 3 and chemotherapy-induced ileus 4. While some studies show benefit 3, others have questioned efficacy in certain types of postoperative ileus 5.
The European Medicines Agency's Committee has recommended against long-term use of metoclopramide due to extrapyramidal side effects and potential for irreversible tardive dyskinesia, particularly in elderly patients 2.
Clinical Pearl
When administering metoclopramide for ileus, monitor for the return of bowel function while being vigilant about neurological side effects. If no improvement is seen within 48-72 hours, consider alternative prokinetic agents or additional interventions rather than continuing ineffective therapy.