Metoclopramide (Reglan) Administration
Metoclopramide is administered at 10 mg orally or IV three to four times daily for most indications, with specific timing of 30 minutes before meals and at bedtime for gastroparesis. 1, 2, 3
Standard Dosing by Route and Indication
Oral Administration
- Gastroparesis: 5-10 mg PO four times daily, taken 30 minutes before each meal and at bedtime 1, 2
- Nausea/vomiting: 10 mg PO three to four times daily 1
- Migraine with nausea: 10 mg PO as adjunctive therapy 1
Intravenous/Intramuscular Administration
- Severe gastroparesis symptoms: 10 mg IV slowly over 1-2 minutes; may continue up to 10 days until symptoms subside, then transition to oral 3
- Postoperative nausea/vomiting: 10 mg IM near the end of surgery (may use 20 mg) 3
- Highly emetogenic chemotherapy: 2 mg/kg IV infused over at least 15 minutes, given 30 minutes before chemotherapy, repeated every 2 hours for two doses, then every 3 hours for three doses 3
- Less emetogenic chemotherapy: 1 mg/kg per dose may be adequate 3
Diagnostic Procedures
- Small bowel intubation: Single 10 mg dose IV over 1-2 minutes if tube hasn't passed pylorus within 10 minutes 3
- Radiological examinations: Single 10 mg dose IV over 1-2 minutes when delayed gastric emptying interferes 3
Pediatric Dosing
Special Populations
Renal Impairment
- Creatinine clearance <40 mL/min: Start at approximately one-half the recommended dose, then titrate based on efficacy and safety 3
Hepatic Impairment
- Metoclopramide undergoes minimal hepatic metabolism; safe use has been described in advanced liver disease patients with normal renal function 3
Critical Administration Details
IV Preparation for High Doses
- For doses exceeding 10 mg, dilute in 50 mL of parenteral solution 3
- Preferred diluent: Normal saline (can be stored frozen up to 4 weeks) 3
- Avoid: Dextrose-5% in water for frozen storage (causes degradation) 3
- Diluted solutions may be stored up to 48 hours if protected from light, or 24 hours under normal light 3
Infusion Rate
- Chemotherapy-related nausea: Infuse over at least 15 minutes 3
- Standard IV bolus: Administer slowly over 1-2 minutes 3
Duration of Therapy
- Oral therapy: Recommended for 4-12 weeks maximum 4
- Parenteral therapy: Should be limited to 1-2 days 4
Critical Safety Precautions
Contraindications
- Seizure disorders 1
- Pheochromocytoma 1
- GI bleeding or obstruction 1
- Concurrent MAO inhibitors or tricyclic antidepressants 5
High-Risk Populations for Tardive Dyskinesia
The risk of tardive dyskinesia is approximately 0.1% per 1000 patient-years (far lower than previously estimated 1-10%), but certain groups require heightened caution: 6
- Elderly females 6
- Diabetic patients 6
- Liver or kidney failure 6
- Patients on concurrent antipsychotic medications 6
Monitoring Requirements
- Monitor for extrapyramidal symptoms (dystonic reactions, akathisia, tardive dyskinesia), especially with high doses or prolonged use 2
- If acute dystonic reactions occur: Administer 50 mg diphenhydramine IM; symptoms usually subside 3
- Akathisia typically occurs only when peak plasma concentrations exceed 100 ng/mL 7
Common Pitfalls to Avoid
- Do not use dextrose-5% in water for frozen storage of diluted metoclopramide—it causes drug degradation 3
- Avoid long-term use beyond 12 weeks orally or 2 days parenterally to minimize tardive dyskinesia risk 4
- Do not exceed recommended doses without careful consideration, as adverse effects correlate with plasma concentrations above 100 ng/mL 7
- Be aware that even short-term, low-dose use (as little as 30 mg total over several days) can rarely cause severe, long-lasting adverse effects lasting months 8