Recommended Oral Metoclopramide Dosing
The standard oral dose of metoclopramide for adults is 10 mg taken three to four times daily, typically administered 30 minutes before meals and at bedtime, with treatment duration limited to a maximum of 5 days and a maximum daily dose of 30 mg to minimize the risk of serious neurological adverse effects. 1, 2
Adult Dosing by Indication
Standard Nausea/Vomiting and Gastroparesis
- 10 mg orally three to four times daily (30 minutes before meals and at bedtime) 1, 2
- Maximum daily dose: 30 mg/day 1
- Maximum treatment duration: 5 days to reduce risk of extrapyramidal disorders and tardive dyskinesia 1
- For diabetic gastroparesis specifically, the FDA-approved regimen is 10 mg four times daily for 4-12 weeks, though European guidelines now recommend limiting to 5 days 2, 1
Hiccups (Intractable)
- 5-20 mg orally or intravenously as needed 3
- Can be titrated up to a maximum of 3-4 administrations daily 3
GERD-Related Cough (Historical Use)
- 10 mg three times daily was used in older studies, though dosing was often not precisely specified 4
- This indication requires prolonged therapy (months), which conflicts with current safety recommendations limiting use to 5 days 4, 1
Pediatric Dosing
Small Bowel Intubation/Radiological Examination
- Ages 6-14 years: 2.5-5 mg as a single dose 2
- Under 6 years: 0.1 mg/kg as a single dose 2
- Over 14 years: 10 mg (adult dose) 2
Chemotherapy-Induced Nausea (IV dosing primarily studied)
- Doses of 2 mg/kg IV have been studied in children, though this carries a 15% risk of extrapyramidal reactions 5
- Oral dosing for CINV in children is less well-established 6
Critical Safety Considerations
European regulatory agencies have restricted metoclopramide use to minimize serious neurological complications: 1
- Maximum 30 mg/day (not the older 40 mg/day dosing)
- Maximum 5 days duration (not weeks to months as previously practiced)
- These restrictions apply to all indications to prevent tardive dyskinesia and extrapyramidal symptoms
High-Risk Populations Requiring Dose Reduction
- Renal impairment (creatinine clearance <40 mL/min): Start at approximately one-half the recommended dose 2
- Elderly patients (>59 years): May require dose reduction due to higher risk of adverse effects 1
- Hepatic impairment: Use with caution, though minimal hepatic metabolism occurs 2
Absolute Contraindications
- History of tardive dyskinesia or extrapyramidal symptoms 7
- Pheochromocytoma 3
- Seizure disorders 3
- GI bleeding or obstruction 3
- Children under 1 year of age (regulatory contraindication) 6
Common Pitfalls to Avoid
The most critical error is prescribing metoclopramide for prolonged periods (weeks to months) as was common practice historically. 1 While the FDA label allows 4-12 weeks for gastroparesis 2, European guidelines now strongly recommend limiting all use to 5 days maximum due to cumulative neurological risks 1. This creates a clinical dilemma for chronic conditions like gastroparesis, where the 5-day limit may be insufficient.
Extrapyramidal symptoms occur in approximately 9% of pediatric patients and are more common in younger adults and children than older adults 6, 5. These reactions are reversible but distressing and can include dystonia, akathisia, and restlessness 6.
QT prolongation and cardiac arrhythmias can occur with repeated dosing, particularly in patients with other risk factors 3.