What is the recommended dosing regimen for metoclopramide (metoclopramide) and omeprazole (omeprazole) IV (intravenous)?

Recommended Dosing for IV Metoclopramide and Omeprazole

For metoclopramide, administer 10 mg IV every 6 hours (four times daily), and for omeprazole, use an 80 mg IV bolus followed by 8 mg/hour continuous infusion for 72 hours in high-risk gastrointestinal bleeding scenarios. 1

Omeprazole IV Dosing

High-Risk Upper GI Bleeding (Post-Endoscopic Therapy)

• Standard regimen: 80 mg IV bolus, then 8 mg/hour continuous infusion for 72 hours 1
• This represents a class effect applicable to omeprazole or pantoprazole, with Level I evidence demonstrating decreased rebleeding rates after successful endoscopic hemostasis 1
• The continuous infusion maintains intragastric pH >6, which is critical for clot stabilization and preventing rebleeding 1

Pre-Endoscopy Empirical Therapy

• Alternative approach: 80 mg IV bolus plus 40 mg IV every 8 hours for 1 day, though this may be suboptimal compared to continuous infusion 1
• Consider high-dose therapy while awaiting endoscopy, though evidence is weaker (Level III) 1

Duration Considerations

• After 5 days of once-daily administration, doses as low as 10 mg IV become effective at reducing 24-hour intragastric acidity, but initial therapy requires higher dosing 2
• On day 1, even 40 mg IV may not maintain pH >4 in all patients, supporting the high-dose bolus-infusion strategy 2

Metoclopramide IV Dosing

Standard Antiemetic/Prokinetic Dosing

• 10 mg IV every 6 hours (four times daily) for nausea, vomiting, or gastroparesis 1, 3
• Can be administered 30 minutes before meals and at bedtime when transitioning to oral therapy 3

Maximum Daily Dose Restrictions

• Critical safety limit: Do not exceed 30 mg/day total dose 3
• Duration limit: Restrict use to ≤5 days to minimize risk of extrapyramidal disorders and tardive dyskinesia 3
• These restrictions are particularly important given the European Medicines Agency's safety warnings about neurological adverse effects 3

Dose Adjustments

• Elderly patients (>59 years) may require dose reduction due to higher risk of adverse effects 3
• Use with extreme caution in younger patients who have increased susceptibility to acute extrapyramidal reactions 4

Combined Therapy Considerations

When Using Both Medications Together

• In emergency cesarean section, the combination of omeprazole 40 mg IV plus metoclopramide 10 mg IV significantly reduced acid aspiration risk 5
• For GERD refractory to H2-blockers, omeprazole alone (20 mg daily) proved superior to ranitidine plus metoclopramide (10 mg four times daily), with the combination therapy significantly increasing adverse events 6
• Key caveat: Adding metoclopramide to proton pump inhibitors does not improve efficacy for GERD and increases side effects 6

Practical Administration

• Both can be given via IV push or short infusion 1
• For upper GI bleeding, prioritize the omeprazole bolus-infusion protocol over standard dosing 1
• Metoclopramide should be given on a scheduled basis (not PRN) when used for breakthrough nausea 1

Critical Safety Warnings

Metoclopramide Precautions

• Avoid in patients with seizure disorders, pheochromocytoma, or GI obstruction 3
• Monitor closely for extrapyramidal symptoms, especially in patients <30 years old 4
• Consider prophylactic diphenhydramine to reduce extrapyramidal reactions 4

Drug Interactions

• Omeprazole may inhibit oxidative metabolism of concurrent medications, though generally less than cimetidine (exception: diazepam) 7
• Both medications have excellent safety profiles when used appropriately and for limited duration 1, 3