From the Guidelines
Erythromycin is a recommended prokinetic agent for enhancing gastrointestinal motility in critically ill patients, particularly those with feeding intolerance, at a dose of 100-250 mg intravenously three times a day for 2-4 days. The use of erythromycin as a prokinetic agent is supported by a meta-analysis of six studies, which found a significant advantage in terms of better enteral feeding tolerance [ 1 ]. The effectiveness of erythromycin is decreased to one third after 72 hours, and it should be discontinued after three days [ 1 ].
Key Points
- Erythromycin is effective in promoting gastric motility and improving enteral feeding tolerance in critically ill patients [ 1 ].
- The recommended dose is 100-250 mg intravenously three times a day for 2-4 days [ 1 ].
- Erythromycin should be considered when gastric residual volume (GRV) is >500 mL/6 h, and enteral feeding should be delayed in such cases [ 1 ].
- The use of prokinetic agents, including erythromycin, is associated with a lower risk of feeding intolerance, but does not significantly increase mortality [ 1 ].
Mechanism of Action
Erythromycin works by acting as a motilin receptor agonist, stimulating smooth muscle contractions in the GI tract, particularly in the stomach and small intestine [ 1 ]. This mechanism differs from its antibiotic action.
Side Effects
Side effects of erythromycin may include abdominal cramping, nausea, vomiting, and QT prolongation with IV administration [ 1 ]. Tachyphylaxis (diminishing response) often develops with continued use, typically after 2-4 weeks, limiting its long-term effectiveness [ 1 ].
Comparison with Other Prokinetic Agents
Erythromycin is more effective than metoclopramide in promoting gastric motility and improving enteral feeding tolerance [ 1 ]. However, other agents like metoclopramide or domperidone may be preferred for longer-term management of motility disorders due to the risk of tachyphylaxis with erythromycin [ 1 ].
From the Research
Role of Erythromycin as a Prokinetic Agent
- Erythromycin, a macrolide antibiotic, exhibits prokinetic effects by enhancing antral contractility and accelerating gastric emptying rates, primarily by stimulating motilin receptors 2.
- The prokinetic effects of erythromycin have been investigated in various gastrointestinal motility disorders, including gastroparesis, and in critically ill patients 3, 4, 5.
Mechanism of Action
- Erythromycin stimulates motilin receptors, leading to increased contractile force and accelerated intraluminal transit 3.
- The optimal dosage form of erythromycin for use as a prokinetic agent is the suspension form, which has a shorter lag time and earlier time to maximum concentration compared to the tablet form 2.
Clinical Use
- Erythromycin has been used as a prokinetic agent in infants and children with gastrointestinal dysmotility, with beneficial effects in promoting tolerance of enteral feeds or enhancing gastrointestinal motility 4.
- In critically ill patients, enteral erythromycin in combination with metoclopramide has been shown to be effective in improving enteral feed tolerance, with an optimal dose of 125 mg twice daily 5.
- However, the use of erythromycin as a prokinetic agent raises concerns about promoting the emergence of macrolide resistance, and alternative agents should be used whenever possible 3, 6.
Safety and Efficacy
- Erythromycin has been shown to be effective and safe when used as a prokinetic agent, with no serious adverse effects reported in most studies 4, 5.
- However, the risk of promoting antibiotic resistance and the potential for adverse effects, such as diarrhea and Clostridium difficile disease, should be carefully considered when using erythromycin as a prokinetic agent 3, 6.