Is Reglan (metoclopramide) effective for treating ileus?

Metoclopramide (Reglan) is Not Recommended for Treating Ileus

Metoclopramide is not recommended for treating ileus in adult surgical patients as there is insufficient evidence supporting its effectiveness in expediting the resolution of ileus. 1

Mechanism of Action and Pharmacology

• Metoclopramide stimulates motility of the upper gastrointestinal tract by sensitizing tissues to acetylcholine, increasing gastric tone and amplitude of contractions, relaxing the pyloric sphincter, and increasing peristalsis of the duodenum and jejunum 2, 3
• It has little to no effect on colonic motility, which limits its utility in treating ileus affecting the lower GI tract 2
• The drug works by antagonizing central and peripheral dopamine receptors and has both prokinetic and antiemetic properties 3

Evidence on Efficacy for Ileus

• A systematic review and meta-analysis by the Eastern Association for the Surgery of Trauma found that metoclopramide was not effective in expediting the resolution of ileus in adult surgical patients 1
• A prospective randomized trial of 100 consecutive patients undergoing elective abdominal colorectal surgery showed that metoclopramide did not significantly alter the course of postoperative ileus compared to no treatment 4
• While some case reports suggest potential benefit in specific scenarios such as vincristine-induced ileus 5 or spinal cord injury-related ileus 6, these represent limited evidence from individual cases

Current Guideline Recommendations

• The National Comprehensive Cancer Network (NCCN) guidelines mention metoclopramide as a consideration only when gastroparesis is suspected in the context of constipation, not specifically for ileus 7
• In patients with months to weeks of life expectancy, prokinetic agents like metoclopramide (10-20 mg PO QID) may be considered as part of constipation management, but not as a primary treatment for ileus 7
• Guidelines for perioperative care in elective colonic surgery do not recommend metoclopramide for prevention or treatment of postoperative ileus 7

Safety Concerns and Adverse Effects

• Metoclopramide carries significant risks, including extrapyramidal side effects and potentially irreversible tardive dyskinesia, especially with prolonged use 7
• The European Medicines Agency's Committee recommends against long-term use of metoclopramide due to these safety concerns 7
• FDA warnings highlight serious side effects including abnormal muscle movements, uncontrolled spasms of face and neck muscles, depression, and suicidal thoughts 2
• Metoclopramide should not be used in patients with mechanical bowel obstruction, as stated in the FDA labeling 2

Alternative Approaches for Ileus

• Early enteral nutrition (EEN) is strongly recommended to expedite resolution of ileus in patients who have undergone abdominal surgery 1
• EEN facilitates return of normal bowel function, helps achieve enteral nutrition goals, and reduces hospital length of stay 1
• Other interventions that may help prevent postoperative ileus include mid-thoracic epidural analgesia, avoidance of fluid overloading, and avoidance of nasogastric decompression 7
• Chewing gum has shown positive effects on postoperative duration of ileus and can be recommended 7

Conclusion

While metoclopramide has theoretical benefits for upper GI motility, current evidence does not support its use for treating ileus. Early enteral nutrition remains the most evidence-based approach for expediting resolution of ileus in surgical patients.