What is the recommended daily dose of Reglan (metoclopramide)?

Recommended Daily Dose of Metoclopramide (Reglan)

The standard daily dose of metoclopramide is 10 mg orally or IV three to four times daily (total 30-40 mg/day), but current European safety guidelines recommend limiting the maximum daily dose to 30 mg/day and restricting treatment duration to 5 days or less to minimize the risk of serious neurological complications. 1, 2

Standard Dosing by Indication

Nausea, Vomiting, and Gastroparesis

• 10 mg administered 30 minutes before meals and at bedtime (four times daily, total 40 mg/day) is the traditional dosing for diabetic gastroparesis 1, 2
• For general nausea and vomiting, 10 mg three to four times daily (oral or IV) is recommended 1
• The FDA label specifies doses of 10 mg may be given slowly IV over 1-2 minutes 2

High-Dose Chemotherapy-Induced Nausea

• 2 mg/kg IV for highly emetogenic drugs (cisplatin, dacarbazine), given 30 minutes before chemotherapy, repeated every 2 hours for two doses, then every 3 hours for three doses 2
• For less emetogenic regimens, 1 mg/kg per dose may be adequate 2
• Infusions should be given slowly over at least 15 minutes 2

Other Indications

• Postoperative nausea/vomiting: 10-20 mg IM near end of surgery 2
• Hiccups: 5-20 mg orally or IV, up to 3-4 administrations daily 3
• Small bowel intubation/radiological exams: Single 10 mg dose IV 2

Critical Safety Considerations and Maximum Dosing

The European Medicines Agency has issued important safety restrictions that supersede older dosing recommendations: 1

• Maximum daily dose: 30 mg/day (not the traditional 40 mg/day) 1
• Maximum treatment duration: 5 days for most indications 1
• These restrictions apply to minimize risk of extrapyramidal disorders and tardive dyskinesia 1

This creates a clinical dilemma, as gastroparesis traditionally requires longer treatment courses. The FDA label describes therapy for "four to 12 weeks" for oral preparations 2, but this conflicts with current European safety data limiting use to 5 days 1. When prolonged therapy is considered necessary, the risks of serious neurological complications must be carefully weighed against benefits.

Special Population Dosing

Renal Impairment

• For creatinine clearance <40 mL/min, initiate therapy at approximately one-half the recommended dosage 2
• Five of six reported cases of metoclopramide-induced parkinsonism occurred in patients with renal failure 4
• Metoclopramide is excreted principally through the kidneys, making dose reduction critical in renal dysfunction 2

Elderly Patients

• Patients over 59 years may require dose reduction due to higher risk of adverse effects 1
• Consider lower starting dosages and slower titration 5

Hepatic Impairment

• Metoclopramide undergoes minimal hepatic metabolism (simple conjugation only) 2
• Safe use has been described in advanced liver disease when renal function is normal 2

Administration Routes and Pharmacokinetics

• Oral, IV, IM, and subcutaneous routes are all effective 2, 6
• Subcutaneous administration of 10 mg every 6 hours achieved peak concentrations of 99.7 ± 47.1 ng/mL at 30 minutes, with return to trough by 4 hours 6
• Nasal spray formulation (10-14 mg) is absorbed even with delayed gastric emptying, though efficacy data show benefit in women but not men with diabetic gastroparesis 7

Common Pitfalls and Contraindications

Absolute contraindications: 1, 3

• Pheochromocytoma
• Seizure disorders
• GI bleeding or obstruction
• Severe renal or hepatic impairment (requires dose adjustment)

Serious adverse effects to monitor: 5, 8, 4

• Extrapyramidal symptoms (restlessness, dystonic reactions, parkinsonism)
• Tardive dyskinesia (can occur even with short-term, low-dose use)
• QT prolongation and torsades de pointes with repeated doses 3
• One case report documented severe, long-lasting neurological effects (twitches, tremors, anxiety, depression) lasting 10-13 months after only 30 mg total oral dose over a few days 8

For acute dystonic reactions: Inject 50 mg diphenhydramine IM 2

Clinical Algorithm for Dosing Decision

1. Verify no contraindications (pheochromocytoma, seizures, GI obstruction) 1, 3
2. Assess renal function: If CrCl <40 mL/min, reduce dose by 50% 2
3. Consider patient age: Elderly patients may need dose reduction 1
4. Select appropriate dose:
   • Standard indications: 10 mg 3-4 times daily (max 30 mg/day) 1
   • High-dose chemotherapy: 1-2 mg/kg per protocol 2
5. Limit duration to ≤5 days when possible 1
6. If longer therapy needed: Carefully document risk-benefit discussion and monitor closely for neurological symptoms