Metoclopramide (Reglan) Dosing for Ileus
For treatment of ileus, metoclopramide should be administered at 10-20 mg IV every 6 hours initially, with transition to oral therapy at 10 mg four times daily once improvement is noted. 1
Dosing Regimen
Initial Treatment
- Start with metoclopramide 10 mg IV every 6 hours 1
- If severe symptoms persist, increase to 20 mg IV every 6 hours 1
- For fulminant Clostridium difficile infection with ileus, metoclopramide can be used as a prokinetic agent at 10-20 mg PO three times a day 2
Maintenance/Oral Therapy
- Transition to oral administration at 10 mg PO four times daily once improvement is observed 1
- Continue treatment until resolution of ileus (typically 3-10 days) 1
- Discontinue if no response after 48-72 hours 1
Monitoring and Precautions
Before Initiating Therapy
- Confirm diagnosis of ileus (absence of bowel sounds, abdominal distension, absence of flatus) 1
- Rule out mechanical obstruction before initiating therapy 1
- QTc monitoring may be necessary for prolonged use 1
During Treatment
- Monitor closely for extrapyramidal side effects, especially in elderly patients 1
- Watch for signs of resolution: return of bowel sounds and passage of flatus 1
- Avoid prolonged use due to risk of tardive dyskinesia 1
Evidence Considerations
The evidence supporting metoclopramide for ileus shows mixed results:
- A 2019 practice management guideline from the Eastern Association for the Surgery of Trauma found that metoclopramide was not effective in expediting resolution of postoperative ileus 3
- However, case reports have shown effectiveness in specific scenarios such as vincristine-induced ileus 4
- A study in gastric cancer patients showed that metoclopramide combined with epidural pain control reduced time to resumption of oral diet after gastrectomy and intraperitoneal chemotherapy 5
- Another study found no significant difference in postoperative ileus duration after colorectal surgery 6
Common Pitfalls and Caveats
- Avoid use in patients with gastrointestinal obstruction, hemorrhage, or perforation 1
- Metoclopramide should not be used long-term due to risk of extrapyramidal side effects and tardive dyskinesia 1
- The European Medicines Agency recommends against prolonged use of metoclopramide 1
- For fulminant Clostridium difficile infection with ileus, intravenously administered metronidazole (500 mg every 8 hours) should be used in addition to oral or rectal vancomycin 2
- If ileus persists despite metoclopramide, consider combining with other treatments such as glycerine suppositories, mineral oil retention enemas, and bisacodyl 1