What is the recommended dosage and administration of metoclopramide (Reglan) for patients requiring prescription metoclopramide?

Metoclopramide Dosing and Administration

The standard dose of metoclopramide is 10 mg administered orally or intravenously three to four times daily for most indications, with a critical safety restriction limiting treatment to a maximum of 5 days and 30 mg/day to minimize the risk of serious extrapyramidal disorders. 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
• For severe symptoms requiring IV administration, give slowly over 1-2 minutes 2
• Maximum daily dose should not exceed 30 mg/day 1
• Treatment duration must be limited to 5 days or less to reduce neurological risks 1

Diabetic Gastroparesis

• 10 mg administered 30 minutes before meals and at bedtime (four times daily) 1
• If severe symptoms are present, initiate therapy with IV or IM metoclopramide 10 mg given slowly over 1-2 minutes 2
• Parenteral administration may be required for up to 10 days before transitioning to oral therapy 2
• This indication conflicts with the European safety restriction of 5-day maximum duration, requiring careful risk-benefit assessment 1

Chemotherapy-Induced Nausea and Vomiting

• For highly emetogenic regimens (cisplatin, dacarbazine): 2 mg/kg per dose 2
• For less emetogenic regimens: 1 mg/kg per dose 2
• Administer via IV infusion over at least 15 minutes, starting 30 minutes before chemotherapy 2
• Repeat every 2 hours for two doses, then every 3 hours for three doses 2
• Doses exceeding 10 mg should be diluted in 50 mL of parenteral solution (preferably normal saline) 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

Pregnancy-Related Nausea and Vomiting

• Metoclopramide is recommended as second-line therapy for hyperemesis gravidarum after failure of first-line treatments (doxylamine/pyridoxine, phenothiazines) 3
• Standard dosing applies, though specific doses are not detailed in pregnancy guidelines 3
• Important safety note: Metoclopramide has fewer adverse effects (drowsiness, dizziness, dystonia) compared to promethazine and no increased risk of congenital defects 3
• Withdraw immediately if extrapyramidal symptoms develop 3

Small Bowel Intubation

• Adults and pediatric patients >14 years: 10 mg IV (undiluted, over 1-2 minutes) 2
• Pediatric patients 6-14 years: 2.5-5 mg IV 2
• Pediatric patients <6 years: 0.1 mg/kg IV 2

Administration Routes and Considerations

Oral Administration

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

Intravenous Administration

• For doses ≤10 mg: administer undiluted over 1-2 minutes 2
• For doses >10 mg: dilute in 50 mL parenteral solution and infuse over at least 15 minutes 2
• Preferred diluent is normal saline (can be frozen for up to 4 weeks) 2
• Other compatible solutions (D5W, Ringer's, lactated Ringer's) may be stored up to 48 hours if protected from light, or 24 hours under normal light 2

Intramuscular Administration

• 10 mg IM is appropriate for postoperative nausea or when oral route is unavailable 4, 2

Subcutaneous Administration

• 10 mg SC every 6 hours has been studied for gastroparesis with good efficacy and tolerability 5
• Peak serum concentrations occur at 30 minutes (99.7 ± 47.1 ng/mL) 5

Special Populations

Renal Impairment

• For creatinine clearance <40 mL/min: initiate at approximately one-half the recommended dose 2
• Titrate based on clinical efficacy and safety 2

Hepatic Impairment

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

Elderly Patients

• May require dose reduction due to higher risk of adverse effects 1
• Patients over 59 years warrant particular caution 1

Critical Safety Considerations

Extrapyramidal Symptoms

• If acute dystonic reactions occur: administer 50 mg diphenhydramine IM immediately 2
• Symptoms usually subside rapidly with treatment 2
• Extrapyramidal effects are more common with prolonged use or high doses 6
• Withdraw metoclopramide immediately if these symptoms develop 3

Tardive Dyskinesia Risk

• Risk increases with duration of treatment and cumulative dose 4
• This is the primary reason for the 5-day maximum treatment duration recommendation 1
• Long-lasting adverse effects (twitches, jerks, tremors) can persist for months even after short-term, low-dose use 7

Other Serious Adverse Effects

• QT interval prolongation and potential for torsades de pointes with repeated doses 8
• Common but less serious effects include fatigue, drowsiness, dizziness, and mood changes 4

Absolute Contraindications

• Avoid in patients with:
  • Pheochromocytoma 1, 8
  • Seizure disorders 1, 8
  • GI bleeding or obstruction 1, 8
  • Severe renal or hepatic impairment (requires dose adjustment) 8

Clinical Pearls

Colonoscopy Preparation

• For patients prone to hiccups during colonoscopy prep: 10 mg IV approximately 30 minutes before purge 4
• Can be repeated every 4-6 hours if needed for prokinetic and antiemetic effects 1

Hiccups

• 5-20 mg orally or IV for intractable hiccups 8
• Can be titrated to maximum of 3-4 administrations daily 8
• Both oral and IV routes demonstrate similar efficacy when GI absorption is intact 8

Migraine with Nausea

• 10 mg orally or IV as adjunctive therapy 1

Key Dosing Algorithm

1. Determine indication and severity
2. Select appropriate dose:
   • Most indications: 10 mg
   • Highly emetogenic chemotherapy: 2 mg/kg
   • Pediatric intubation: weight-based (see above)
3. Choose route:
   • Oral for mild-moderate symptoms
   • IV/IM for severe symptoms or inability to take oral medications
4. Adjust for renal impairment (reduce by 50% if CrCl <40 mL/min)
5. Limit duration to 5 days maximum (except gastroparesis, which may require longer treatment with careful monitoring)
6. Monitor for extrapyramidal symptoms and discontinue immediately if they occur