Maximum Dosage of Metoclopramide
The maximum recommended daily dose of metoclopramide is 30 mg per day, with treatment duration strictly limited to 5 days to minimize the risk of serious neurological complications including extrapyramidal disorders and tardive dyskinesia. 1, 2
Regulatory-Mandated Dosing Limits
The European Medicines Agency has established clear safety parameters that should guide all metoclopramide prescribing:
- Maximum daily dose: 30 mg/day 1
- Maximum treatment duration: 5 days 1
- These restrictions apply to all indications to reduce the risk of extrapyramidal disorders and tardive dyskinesia 1, 2
Standard Dosing by Indication
Nausea, Vomiting, and Gastroparesis
- Standard dose: 10 mg orally or IV, three to four times daily (total 30-40 mg/day) 1
- For gastroparesis specifically: 10 mg administered 30 minutes before meals and at bedtime (four times daily) 1
- The traditional dosing of 10 mg four times daily totals 40 mg/day, which exceeds current European safety recommendations of 30 mg/day maximum 1, 3
Hiccups
- Dosing range: 5-20 mg orally or intravenously 2
- Can be titrated up to a maximum of 3-4 administrations daily 2
- For intractable hiccups: 10-20 mg IV every 6 hours (maximum 3-4 doses daily) 2
Critical Safety Considerations
Neurological Risks
The most concerning adverse effects are dose-dependent and duration-dependent:
- Extrapyramidal reactions occur in 15-16% of patients even at standard doses 4, 5
- Tardive dyskinesia risk increases significantly with prolonged use beyond 5 days 1
- Long-lasting adverse effects (lasting up to 13 months) have been documented even after short-term, low-dose use (total 30-40 mg over several days) 6
Age-Related Considerations
- Younger patients have increased risk of acute extrapyramidal reactions 5
- Patients over 59 years may require dose reduction 1
- Children receiving doses ≥2 mg/kg showed 15% incidence of extrapyramidal reactions and 33% incidence of akathisia 5
High-Dose Exceptions (Historical Context Only)
While older oncology literature describes continuous high-dose metoclopramide (2 mg/kg/24 hours for 84-90 hours) for cisplatin-induced emesis 4, this practice conflicts with current safety recommendations limiting use to 5 days and 30 mg/day maximum 1. Modern antiemetic regimens have largely replaced high-dose metoclopramide due to superior alternatives with better safety profiles.
Absolute Contraindications
Avoid metoclopramide entirely in patients with:
- Pheochromocytoma 2
- Seizure disorders 1, 2
- GI bleeding or obstruction 1, 2
- Severe renal or hepatic impairment (requires dose adjustment if used) 2
Clinical Pitfall to Avoid
The most common prescribing error is exceeding the 5-day treatment duration, particularly for gastroparesis or GERD-related symptoms that traditionally required prolonged therapy 1. The 10 mg three times daily dosing used in older GERD studies is no longer appropriate given current safety data limiting treatment to 5 days maximum 1.