What is the recommended dosing for metoclopramide (Reglan) in adults?

Metoclopramide Dosing for Adults

The standard adult dose of metoclopramide is 10 mg administered orally or intravenously three to four times daily for nausea and vomiting, with treatment duration strictly limited to a maximum of 5 days and a maximum daily dose of 30 mg to minimize the risk of serious neurological complications. 1, 2

Standard Dosing by Indication

Nausea and Vomiting (General)

• 10 mg orally or IV three to four times daily is the recommended dose 1
• Maximum daily dose should not exceed 30 mg/day 1
• Treatment duration must be limited to 5 days or less to reduce risk of extrapyramidal disorders and tardive dyskinesia 1

Diabetic Gastroparesis

• 10 mg administered 30 minutes before meals and at bedtime (four times daily) 1
• For severe symptoms, initiate therapy with IV or IM metoclopramide 10 mg given slowly over 1-2 minutes 2
• May require up to 10 days of parenteral therapy before transitioning to oral administration 2

Cancer Chemotherapy-Induced Nausea and Vomiting

• Highly emetogenic regimens (cisplatin, dacarbazine): 2 mg/kg IV infused over at least 15 minutes 2
• Less emetogenic regimens: 1 mg/kg per dose may be adequate 2
• Administer 30 minutes before chemotherapy, repeat every 2 hours for two doses, then every 3 hours for three doses 2
• For doses exceeding 10 mg, dilute in 50 mL of parenteral solution 2

Postoperative Nausea and Vomiting

• 10 mg IM given near the end of surgery 2
• Doses of 20 mg may be used in select cases 2

Hiccups

• 5-20 mg orally or intravenously 3
• Can be titrated up to a maximum of 3-4 administrations daily 3
• For cancer treatment-associated hiccups: 10-20 mg IV every 6 hours 3

Administration Routes and Timing

Oral Administration

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

Intravenous Administration

• Single doses of 10 mg or less: administer slowly over 1-2 minutes 2
• Infusions: administer over at least 15 minutes 2
• May be given undiluted for single doses or diluted in 50 mL for higher doses 2

Intramuscular Administration

• 10 mg IM is standard for postoperative nausea 2

Critical Safety Considerations and Duration Limits

European regulatory agencies mandate a maximum treatment duration of 5 days across all indications to minimize serious neurological complications including tardive dyskinesia and extrapyramidal symptoms. 1

Key Safety Points

• The 30 mg/day maximum and 5-day duration limit supersede older dosing recommendations that suggested longer treatment courses 1
• Extrapyramidal reactions are more common in younger patients and with higher doses 4
• If acute dystonic reactions occur, administer 50 mg diphenhydramine IM 2
• Prolonged QT interval and torsades de pointes can occur with repeated doses 3

Absolute Contraindications

• Seizure disorders 1, 3
• Pheochromocytoma 1, 3
• GI bleeding or obstruction 1, 3

Dose Adjustments for Renal Impairment

• Creatinine clearance <40 mL/min: initiate therapy at approximately one-half the recommended dosage 2
• Metoclopramide is excreted principally through the kidneys 2
• Titrate based on clinical efficacy and safety 2

Dose Adjustments for Hepatic Impairment

• Metoclopramide undergoes minimal hepatic metabolism 2
• Safe use has been described in patients with advanced liver disease when renal function is normal 2

Elderly Patients

• Patients over 59 years may require dose reduction due to higher risk of adverse effects 1

Common Pitfalls to Avoid

• Do not exceed 5 days of treatment for any indication, as older literature suggesting 4-12 weeks of oral therapy conflicts with current safety recommendations 1, 5
• Do not use for chronic GERD requiring prolonged therapy, as this conflicts with the 5-day safety limit 1
• Do not combine with other medications that prolong QT interval without careful monitoring 3
• Be aware that even short-term, low-dose use (30 mg total over a few days) has been associated with severe, long-lasting extrapyramidal symptoms in rare cases 6