What are the contraindications for Reglan (Metoclopramide) IV?

Contraindications of Reglan IV (Metoclopramide)

Metoclopramide IV is absolutely contraindicated in patients with gastrointestinal hemorrhage, mechanical obstruction, perforation, pheochromocytoma, known drug hypersensitivity, and in epileptic patients or those receiving medications likely to cause extrapyramidal reactions. 1

Absolute Contraindications

1. Gastrointestinal conditions where increased motility is dangerous:

   • Gastrointestinal hemorrhage
   • Mechanical obstruction
   • Gastrointestinal perforation

2. Endocrine disorders:

   • Pheochromocytoma (can cause hypertensive crisis due to catecholamine release) 1

3. Neurological conditions:

   • Epilepsy (may increase frequency and severity of seizures)
   • Patients receiving other medications likely to cause extrapyramidal reactions 1

4. Hypersensitivity:

   • Known sensitivity or intolerance to metoclopramide 1

Relative Contraindications and High-Risk Populations

1. Elderly patients:

   • Particularly elderly females (higher risk of extrapyramidal symptoms) 2, 3

2. Patients with metabolic disorders:

   • Diabetes (higher risk of neurological complications) 2, 3

3. Organ dysfunction:

   • Liver failure (altered drug metabolism)
   • Kidney failure (impaired drug clearance) 2, 3

4. Medication interactions:

   • Concomitant antipsychotic therapy (lowers threshold for neurological complications) 2, 3

5. Duration limitations:

   • Use beyond 12 weeks (FDA black box warning due to risk of tardive dyskinesia) 4
   • Parenteral metoclopramide should ideally be limited to 1-2 days 5

Clinical Considerations and Risk Management

• Monitor for extrapyramidal symptoms:

  • Acute dystonic reactions
  • Drug-induced parkinsonism
  • Akathisia
  • Tardive dyskinesia (potentially irreversible) 6

• Dosing considerations:

  • Standard IV dose is typically 10 mg 3-4 times daily 2
  • Use lowest effective dose in high-risk patients 2

• Alternative treatments:

  • Consider alternative medications with better safety profiles for conditions requiring long-term management 2
  • For gastroparesis, domperidone (available outside US) or erythromycin may be alternatives, though erythromycin is only effective short-term due to tachyphylaxis 6

Important Caveats

• Despite the FDA black box warning suggesting a 1-10% risk of tardive dyskinesia with long-term use, more recent evidence suggests the actual risk may be lower, around 0.1% per 1000 patient years 3

• Metoclopramide remains the only FDA-approved medication for diabetic gastroparesis, despite its risks 6, 4

• Even a single dose of metoclopramide can cause acute extrapyramidal symptoms like dystonia and akathisia, requiring prompt recognition and treatment 7

• Regular neurological examinations are recommended if metoclopramide must be used daily to detect early signs of tardive dyskinesia 2