Metoclopramide IV Dosing in Chronic Kidney Disease (CKD)
For patients with chronic kidney disease, the IV metoclopramide dose should be reduced to approximately one-half the recommended dosage when creatinine clearance is below 40 mL/min. 1
Dosing Recommendations
- The standard IV metoclopramide dose for adults is 10 mg administered slowly over 1-2 minutes 1
- In patients with CKD whose creatinine clearance is below 40 mL/min, therapy should be initiated at approximately one-half the recommended dosage (5 mg IV) 1
- Subsequent dose adjustments should be based on clinical efficacy and safety considerations 1
- Metoclopramide is primarily excreted through the kidneys, which necessitates dose adjustment in renal impairment 1, 2
Pharmacokinetics in CKD
- Creatinine clearance correlates with metoclopramide plasma clearance, renal clearance, nonrenal clearance, and elimination half-life 2
- Renal clearance accounts for ≤21% of total plasma clearance, regardless of renal function 2
- Nonrenal clearance is reduced in patients with impaired renal function and accounts for most of the reduction in plasma clearance 2
- The smaller plasma clearance in CKD patients requires dose reduction to avoid drug accumulation 2
Administration Considerations
- IV metoclopramide should be administered slowly over 1-2 minutes to minimize side effects 1
- For doses exceeding 10 mg, metoclopramide injection should be diluted in 50 mL of a parenteral solution (preferably normal saline) 1
- When diluted in compatible solutions, metoclopramide may be stored up to 48 hours if protected from light 1
Hemodialysis Considerations
- Metoclopramide losses during hemodialysis are relatively small compared to total body stores 2
- Compensatory dosage increases are generally unnecessary for most patients on hemodialysis 2
- Hemodialysis is not likely to be effective in cases of metoclopramide overdose 2
Monitoring and Safety
- Monitor for extrapyramidal symptoms, which may be more common in patients with renal impairment due to drug accumulation 1
- If acute dystonic reactions occur, administer 50 mg diphenhydramine intramuscularly 1
- High doses of metoclopramide (>1 mg/kg) may decrease renal plasma flow, which could be clinically significant in patients with already compromised renal function 3
- Normal doses of metoclopramide (<0.2 mg/kg) do not appear to adversely affect renal function in critically ill patients 4
Common Pitfalls to Avoid
- Failing to adjust the dose in patients with CKD can lead to drug accumulation and increased risk of adverse effects 1, 2
- Administering IV metoclopramide too rapidly increases the risk of acute dystonic reactions 1
- Using high doses of metoclopramide in patients receiving nephrotoxic medications may potentially increase nephrotoxicity 3
- Not considering alternative antiemetics in severe CKD - ondansetron may be more effective for uremia-induced nausea and vomiting 5