Metoclopramide Dosing for Gastroparesis
The recommended dose of metoclopramide for gastroparesis is 5-20 mg three to four times daily before meals, with 10 mg three times daily being the standard starting dose. 1, 2, 3
Dosing Regimen
- Initial dose: 10 mg orally three times daily before meals
- Dose range: 5-20 mg three to four times daily
- Maximum duration: Limited to 12 weeks due to risk of tardive dyskinesia
- Renal impairment: For patients with creatinine clearance below 40 mL/min, start at approximately half the recommended dose 3
Administration Considerations
- For severe symptoms, therapy may begin with metoclopramide injection (IM or IV) before transitioning to oral administration 3
- IV doses should be administered slowly over 1-2 minutes
- Take 30 minutes before meals to maximize prokinetic effect 2
Efficacy and Monitoring
- Metoclopramide works by enhancing gastric emptying through dopamine-2 receptor antagonism and stimulating cholinergic activity in the antrum 1
- Clinical studies demonstrate significant improvement in symptoms including nausea, vomiting, fullness, and early satiety compared to placebo 4
- Monitor for:
- Symptom improvement (nausea, vomiting, early satiety, abdominal pain)
- Extrapyramidal symptoms at each visit
- Development of tardive dyskinesia
Important Cautions
- Tachyphylaxis: Efficacy may diminish with chronic use 5
- Tardive dyskinesia risk: The risk is lower than previously estimated (approximately 0.1% per 1000 patient-years) but remains a concern 6
- Higher risk groups for neurological complications:
- Elderly females
- Diabetic patients
- Patients with liver or kidney failure
- Patients on concomitant antipsychotic therapy 6
Side Effects
- Common: Drowsiness, dizziness, fatigue, gastrointestinal disturbances
- Serious: Extrapyramidal symptoms, tardive dyskinesia
- Other CNS effects: Somnolence, depression, hallucinations 2
Drug Interactions
- Use with caution when combined with:
- Antipsychotics
- MAO inhibitors
- Sedatives
- Narcotics 2
- Contraindicated in patients with pheochromocytoma 2
Alternative Treatments
If metoclopramide is ineffective or contraindicated, consider:
- Domperidone (10-20 mg three times daily) - available in US through FDA investigational drug protocol 1, 2
- Erythromycin (100-250 mg three times daily) for short-term use (2-4 days) 2
Remember that optimizing glycemic control is crucial for diabetic patients with gastroparesis, as hyperglycemia can further delay gastric emptying 2.