From the Guidelines
Reglan (Metoclopramide) is contraindicated in the setting of full gastrointestinal obstruction, as it may worsen the condition by increasing muscle contractions in the upper digestive tract, potentially leading to increased pressure, pain, and possible perforation. This is based on the most recent and highest quality study, which recommends against the use of metoclopramide in full bowel obstruction, although it may be considered for partial obstructions 1. The use of metoclopramide in gastrointestinal obstruction could lead to increased morbidity and mortality, as well as decreased quality of life, due to the potential for worsening the obstruction and masking important symptoms that indicate a need for surgical intervention.
Some key points to consider in the management of gastrointestinal obstruction include:
- Decompression with a nasogastric tube and possibly surgical intervention to address the obstruction directly
- Use of antiemetics without prokinetic properties for symptom management if needed
- Consideration of pharmacologic management, including opioids, anticholinergics, and octreotide, to relieve distressing symptoms
- Discussion of risks and benefits of surgical intervention, including mortality, morbidity, and re-obstruction, and consideration of the patient's overall clinical status and prognosis 1.
In terms of specific management strategies, the most recent study recommends:
- Operative management for patients with resectable obstructions
- Endoscopic management, including percutaneous endoscopic gastrostomy tube for drainage and endoscopic stent placement, for patients with non-resectable obstructions
- Pharmacologic management, including opioids, anticholinergics, and octreotide, to relieve distressing symptoms and improve quality of life 1.
From the FDA Drug Label
Metoclopramide should not be used whenever stimulation of gastrointestinal motility might be dangerous, e.g., in the presence of gastrointestinal hemorrhage, mechanical obstruction or perforation.
- Contraindication: Reglan (Metoclopramide) is contraindicated in the setting of gastrointestinal obstruction because it may stimulate gastrointestinal motility, which could be dangerous in this situation 2.
- Key consideration: The drug label explicitly states that metoclopramide should not be used in the presence of mechanical obstruction.
From the Research
Reglan (Metoclopramide) in Gastrointestinal Obstruction
- Reglan (Metoclopramide) may be effective in reducing nausea and vomiting secondary to partial bowel obstructions, as suggested by the MASCC guideline update 3.
- The use of metoclopramide in malignant bowel obstruction is supported by studies, which show improvement in symptoms such as nausea and vomiting 4, 5.
- However, it is essential to note that metoclopramide is a prokinetic agent, and its use in complete bowel obstruction may be contraindicated, as it can increase the risk of bowel perforation.
- In the context of gut dysmotility in the ICU, 'off-label' metoclopramide administration is effective for upper gastrointestinal dysmotility, but it has adverse effects 6.
- The evidence suggests that metoclopramide may be used in the setting of partial bowel obstruction or malignant bowel obstruction, but its use in complete bowel obstruction should be approached with caution, and further studies are needed to clarify its benefits and risks 3, 7, 4, 5, 6.
Key Considerations
- The MASCC guideline update recommends octreotide as the drug of choice in managing malignant bowel obstruction, but suggests that metoclopramide may be effective in reducing nausea and vomiting secondary to partial bowel obstructions 3.
- The use of metoclopramide in combination with other medications, such as dexamethasone and octreotide, may provide rapid improvement in symptoms associated with malignant bowel obstruction and dysfunction 4, 5.
- Further studies are needed to clarify the benefits and risks of metoclopramide in the setting of gastrointestinal obstruction, particularly in complete bowel obstruction 3, 7, 4, 5, 6.