What are the recommended uses and dosing guidelines for Metoclopramide (metoclopramide)?

Metoclopramide: Recommended Uses and Dosing Guidelines

Primary Indications

Metoclopramide is FDA-approved for diabetic gastroparesis, prevention of chemotherapy-induced nausea/vomiting, postoperative nausea/vomiting, and facilitation of small bowel intubation, with standard dosing of 10 mg orally or IV three to four times daily for most indications. 1

Diabetic Gastroparesis

• Standard dose: 10 mg administered 30 minutes before meals and at bedtime (four times daily) 2, 1
• For severe symptoms, initiate therapy with IV or IM metoclopramide 10 mg given slowly over 1-2 minutes 1
• Up to 10 days of parenteral therapy may be required before transitioning to oral administration 1
• Oral metoclopramide 10 mg four times daily significantly reduces nausea, vomiting, fullness, and early satiety compared to placebo 3
• Important caveat: Chronic oral administration may result in loss of gastrokinetic properties over time, with one study showing return to baseline gastric emptying after one month of continuous use 4

Chemotherapy-Induced Nausea and Vomiting

• For highly emetogenic chemotherapy (cisplatin, dacarbazine): 2 mg/kg IV infused over at least 15 minutes, given 30 minutes before chemotherapy 1
• Repeat dosing: every 2 hours for two doses, then every 3 hours for three doses 1
• For less emetogenic regimens: 1 mg/kg per dose may be adequate 1
• Metoclopramide is recommended as first-line for chronic nausea in cancer patients, including opioid-related nausea 5
• For patients with previous opioid-induced nausea, consider prophylactic metoclopramide around-the-clock for the first few days of opioid therapy 5

Nausea and Vomiting in Palliative Care

• Metoclopramide has both central and peripheral antiemetic effects, making it first-line for chronic nausea management 5
• Standard dose: 10-20 mg every 6 hours for gastroparesis 5
• For non-specific nausea/vomiting: 10-40 mg PO or IV every 4-6 hours 5
• Around-the-clock dosing provides greater benefit than PRN administration 5
• If oral route not feasible, use rectal, subcutaneous, or IV administration 5
• For intractable nausea/vomiting, continuous IV or subcutaneous infusions may be necessary 5

Postoperative Nausea and Vomiting

• 10 mg IM administered near the end of surgery; doses up to 20 mg may be used 1

Diagnostic Procedures

• For small bowel intubation: 10 mg IV (adults and pediatrics >14 years) given slowly over 1-2 minutes if tube has not passed pylorus within 10 minutes 1
• Pediatric dosing (6-14 years): 2.5-5 mg; (<6 years): 0.1 mg/kg 1
• Same dosing applies for radiological examinations when delayed gastric emptying interferes with imaging 1

Critical Safety Considerations and Duration Limits

The European Medicines Agency mandates maximum daily dose of 30 mg/day and treatment duration limited to 5 days to minimize risk of extrapyramidal disorders and tardive dyskinesia 2

Key Precautions

• Avoid in patients with seizure disorders, pheochromocytoma, GI bleeding, or obstruction 2
• Monitor for dystonic reactions; treat with diphenhydramine 50 mg IM if they occur 1
• Patients over 59 years may require dose reduction due to higher risk of adverse effects 2
• Black box warning exists regarding risk in elderly dementia patients 5

Renal and Hepatic Impairment

• For creatinine clearance <40 mL/min: initiate at approximately one-half the recommended dosage 1
• Metoclopramide undergoes minimal hepatic metabolism, making it relatively safe in liver disease with normal renal function 1

Route Selection: IV vs. Oral

IV metoclopramide provides faster onset and superior efficacy for rapid gastric emptying (84% pain relief at 1 hour vs. 25% with oral), making it preferred for severe symptoms requiring immediate relief 6

When to Use IV Route

• Severe nausea/vomiting requiring immediate relief 6
• Hospitalized patients with hyperemesis gravidarum not responding to first-line therapy 6
• Intensive care settings with feeding intolerance and high gastric residuals 6
• High-dose chemotherapy regimens 1

When Oral Route is Appropriate

• Outpatient management of less severe nausea/vomiting 6
• Maintenance therapy for diabetic gastroparesis after initial parenteral stabilization 1
• Chronic management when symptoms are controlled 2

Administration Details

IV Administration

• Doses ≤10 mg: administer slowly over 1-2 minutes 1
• Doses >10 mg: dilute in 50 mL parenteral solution and infuse over at least 15 minutes 1
• Preferred diluent: normal saline (can be frozen for up to 4 weeks) 1
• Dilutions in other solutions may be stored up to 48 hours if protected from light, or 24 hours under normal light 1

Oral Administration

• Standard tablets: 5-20 mg per dose 2
• Administer 30 minutes before meals for gastroparesis 2, 1