Reglan (Metoclopramide) is Contraindicated in Status Epilepticus
Metoclopramide should NOT be used in patients with status epilepticus or any seizure disorder, as it is explicitly contraindicated by the FDA and may increase seizure frequency and severity. 1
Why Metoclopramide is Contraindicated
The FDA drug label clearly states that "Metoclopramide should not be used in epileptics or patients receiving other drugs which are likely to cause extrapyramidal reactions, since the frequency and severity of seizures or extrapyramidal reactions may be increased." 1 This is an absolute contraindication, not a relative one.
Key Safety Concerns
Increased seizure risk: Metoclopramide can lower the seizure threshold and increase both the frequency and severity of seizures in patients with epilepsy 1
Extrapyramidal symptoms: The drug causes acute dystonic reactions in approximately 1 in 500 patients at standard doses, with higher risk in younger patients and at higher doses 1
Neuroleptic malignant syndrome: Metoclopramide can cause this life-threatening condition, which would further complicate management of a critically ill patient on mechanical ventilation 1
Appropriate Alternatives for Ventilated Patients with Status Epilepticus
First-Line Treatment
- Benzodiazepines remain the cornerstone of initial therapy, with IV lorazepam or IM/intranasal midazolam as first-line agents 2, 3
Second-Line Antiepileptic Options
Valproate 20-30 mg/kg IV over 5-20 minutes shows 88% efficacy with minimal hypotension risk (0% vs 12% with phenytoin) 2, 3
Levetiracetam 30 mg/kg IV over 5 minutes demonstrates 68-73% efficacy with favorable safety profile and no significant cardiovascular effects 2, 3
Fosphenytoin 20 mg PE/kg IV at maximum 50 mg/min has 84% efficacy but requires continuous ECG and blood pressure monitoring due to cardiovascular risks 2, 3
Refractory Status Epilepticus (Already Intubated)
Propofol 2 mg/kg bolus followed by 3-7 mg/kg/hour infusion is effective for suppressing seizures and is already commonly used for sedation in ventilated patients 4, 2
Midazolam infusion 0.15-0.20 mg/kg IV load, then 1 mg/kg/min continuous infusion, titrated up as needed 2
Pentobarbital 13 mg/kg bolus followed by 2-3 mg/kg/hour infusion shows 92% efficacy for refractory cases 2
Clinical Pitfalls to Avoid
Never use metoclopramide for gastric motility in any patient with active seizures or status epilepticus, regardless of ventilation status 1
Avoid phenytoin if possible in favor of valproate or levetiracetam, as phenytoin causes more hypotension and has lower efficacy (56% success after benzodiazepines) 3
Monitor for Lance-Adams syndrome: Generalized myoclonus with epileptiform discharges may be compatible with good outcome and should not be treated overly aggressively 4