What is the recommended dosage and use of Metoclopramide for nausea and vomiting?

Metoclopramide Dosage and Use for Nausea and Vomiting

For nausea and vomiting, metoclopramide should be administered at a dose of 5-20 mg three to four times daily, with the specific dose depending on the clinical scenario and severity of symptoms. 1

Dosing Guidelines by Indication

Diabetic Gastroparesis

• Initial dose: 10 mg orally three to four times daily before meals and at bedtime 1, 2
• Duration: Trial of at least 4 weeks before determining efficacy 1
• For severe symptoms: Begin with injectable form (IV/IM) before transitioning to oral therapy 2
  • IV administration: 10 mg given slowly over 1-2 minutes
  • Treatment may require up to 10 days before symptoms subside

General Nausea and Vomiting

• Standard dose: 5-20 mg three to four times daily 1
• Administration timing: 30 minutes before meals and at bedtime
• IV formulation (for severe cases): 10 mg given slowly over 1-2 minutes 2

Chemotherapy-Induced Nausea and Vomiting

• IV administration: Given slowly over at least 15 minutes, 30 minutes before chemotherapy 2, 3
• Dosing schedule:
  • Initial dose: 30 minutes before chemotherapy
  • Repeat every 2 hours for two doses, then every 3 hours for three doses
• Dosage:
  • Highly emetogenic regimens: 2 mg/kg per dose
  • Less emetogenic regimens: 1 mg/kg per dose
  • For doses exceeding 10 mg: Dilute in 50 mL of parenteral solution (preferably normal saline)

Postoperative Nausea and Vomiting

• Dose: 10 mg IM near the end of surgery (up to 20 mg may be used) 2, 3

Special Populations

Renal Impairment

• For patients with creatinine clearance below 40 mL/min: Start with approximately half the recommended dose 2, 3
• Adjust based on efficacy and safety considerations

Hepatic Impairment

• No specific dose adjustment required for most hepatic impairment 2, 3
• Safe use has been documented in patients with advanced liver disease and normal renal function

Administration Routes and Formulations

• Oral tablets: Standard formulation for most cases
• Nasal spray: May offer better symptom control than oral tablets in diabetic gastroparesis 4
• IV/IM injection: For severe symptoms or when oral administration is not feasible

Efficacy and Considerations

• Metoclopramide is the only FDA-approved medication for gastroparesis 1
• Clinical trials have demonstrated effectiveness in reducing nausea, vomiting, fullness, and early satiety in diabetic gastroparesis 5
• Nasal spray formulation may provide superior symptom control compared to oral tablets in diabetic gastroparesis patients 4

Important Safety Considerations

1. Black Box Warning: Risk of tardive dyskinesia with prolonged use or high doses

   • Limit therapy duration when possible
   • Risk may be lower than previously estimated 1

2. Medication Overuse: Limit acute therapy to no more than twice weekly to prevent medication-overuse headache 1

3. Adverse Effects: Monitor for:

   • Extrapyramidal symptoms (acute dystonic reactions)
   • Sedation
   • Dizziness
   • Fatigue
   • Anxiety

4. Rare but Serious Adverse Effects: Cases of severe and long-lasting adverse effects have been reported even with short-term, low-dose use 6

Treatment Algorithm

1. Initial Approach:

   • Start with 10 mg three times daily before meals
   • For severe symptoms, begin with injectable form (10 mg IV/IM)

2. Dose Adjustment:

   • If inadequate response: Increase to 10 mg four times daily
   • If side effects occur: Reduce to 5 mg three times daily

3. Duration:

   • Minimum trial of 4 weeks for gastroparesis
   • For acute nausea/vomiting: Use as needed, but limit to avoid medication overuse

4. Alternative Options if metoclopramide fails or is contraindicated:

   • 5-HT3 antagonists (ondansetron 4-8 mg twice or three times daily)
   • Phenothiazines (prochlorperazine 5-10 mg four times daily)
   • NK-1 receptor antagonists for refractory cases

Remember that metoclopramide should be used judiciously due to its potential for serious adverse effects, particularly with prolonged use. Regular monitoring for extrapyramidal symptoms is essential, and therapy should be discontinued if these develop.