Is it appropriate to prescribe Reglan (Metoclopramide) to a 52-year-old male with a history of impaired glucose tolerance (IGT), hyperlipidemia (HLD), non-cancerous sigmoid mass, small bowel obstruction (SBO), status post exploratory laparotomy (ex-lap) with enterotomy and removal of phytobezoar, presenting with abdominal cramping and burping?

From the Guidelines

It would not be appropriate to prescribe Reglan (metoclopramide) for this 52-year-old male patient at this time. The patient's symptoms of nighttime abdominal cramping and burping without nausea, vomiting, abdominal pain, or bowel changes are relatively mild and non-specific. Given his history of small bowel obstruction and prior surgery for phytobezoar removal, these symptoms may represent normal post-surgical changes or mild dysmotility. Reglan carries significant risks including tardive dyskinesia, especially with longer-term use, and should be reserved for more severe cases of gastroparesis or documented gastric emptying disorders, as stated in the most recent guidelines 1. A more appropriate approach would be to first try conservative measures such as:

• avoiding late meals
• elevating the head of the bed
• possibly using an H2 blocker or proton pump inhibitor if reflux is suspected. Additionally, the patient should undergo basic evaluation including physical examination and possibly upper endoscopy to rule out recurrent bezoar or other structural issues before considering prokinetic agents like Reglan. The risk-benefit ratio for Reglan does not favor its use for these mild symptoms without further diagnostic workup, and this is supported by recent studies 1. Other treatment options, such as domperidone and erythromycin, may be considered in the future if the patient's symptoms worsen or do not respond to conservative measures, as mentioned in 1. However, the most recent and highest quality study 1 should be prioritized when making a definitive recommendation.

From the FDA Drug Label

Metoclopramide is a prescription medicine used to: • relieve symptoms of slow stomach emptying in people with diabetes • prevent nausea and vomiting that can happen with cancer chemotherapy • prevent nausea and vomiting that may happen after surgery, if your doctor decides that you should not be treated with a stomach tube and suction • help make it easier to insert a tube into the small intestine in both adults and children, if the tube does not pass into the stomach normally. • to help empty stomach contents or to help barium move through your intestine, when you get an X-ray examination of the stomach or small intestine.

The patient's symptoms of abdominal cramping and burping, especially at night, could be related to gastroparesis or slow stomach emptying. However, the patient does not have a history of diabetes, which is the primary condition for which metoclopramide is used to relieve symptoms of slow stomach emptying. The patient has a history of surgical procedures and small bowel obstruction, which may affect stomach emptying, but the label does not directly address the use of metoclopramide for these conditions. Given the potential serious side effects of metoclopramide, such as tardive dyskinesia and dystonia, and the lack of direct evidence supporting its use for this patient's specific condition, it would be cautious not to prescribe Reglan (metoclopramide) without further evaluation and consideration of alternative treatments 2.

From the Research

Patient Presentation

The patient is a 52-year-old male with a history of impaired glucose tolerance (IGT), hyperlipidemia (HLD), a non-cancerous sigmoid mass, and a history of small bowel obstruction (SBO) with a previous exploratory laparotomy and enterotomy for removal of a phytobezoar. He presents with complaints of abdominal cramping and burping, typically at night, and reports feeling as if his stomach is empty with occasional gas at night. He denies nausea, vomiting, abdominal pain, constipation, diarrhea, fever, or chills, and reports a good appetite.

Consideration of Reglan (Metoclopramide) Prescription

• The patient's symptoms could be indicative of gastroparesis, a condition characterized by delayed gastric emptying due to abnormal gastric motility 3.
• Metoclopramide, the active ingredient in Reglan, is a prokinetic agent commonly used to treat gastroparesis and has been shown to be effective in improving gastric emptying and symptoms in diabetic patients with gastroparesis 4, 5.
• However, long-term use of metoclopramide has been associated with potential adverse effects, including tardive dyskinesia, particularly in elderly patients 6.
• A study on the safety of prolonged use of metoclopramide and domperidone in patients with systemic sclerosis found no significant troublesome side effects, but the study had a small sample size and further research is needed to confirm these findings 7.
• The decision to prescribe Reglan should take into account the patient's medical history, current symptoms, and potential risks and benefits of treatment, as well as consideration of alternative treatment options.