What is the role of Reglan (metoclopramide) in the management of ileus?

Metoclopramide (Reglan) Should NOT Be Used for Ileus

Metoclopramide is not recommended for the treatment of ileus and lacks evidence of efficacy for this indication. Current guidelines and high-quality evidence demonstrate no benefit in expediting resolution of postoperative ileus, and the drug carries significant safety risks including extrapyramidal side effects and potentially irreversible tardive dyskinesia 1.

Evidence Against Use in Ileus

Guideline Recommendations

• The NCCN guidelines do not recommend metoclopramide for ileus treatment, mentioning it only as a consideration when gastroparesis is suspected in the context of constipation—a distinctly different clinical entity 1
• Guidelines for perioperative care in elective colonic surgery explicitly do not recommend metoclopramide for prevention or treatment of postoperative ileus 1
• The 2020 Gut guidelines on severe chronic small intestinal dysmotility state that "domperidone and metoclopramide are no longer used in the long term" for vomiting in dysmotility disorders 2

Clinical Trial Evidence

• The 2019 Eastern Association for the Surgery of Trauma (EAST) practice management guideline conducted a systematic review and meta-analysis of 45 studies and concluded that metoclopramide was not effective in expediting the resolution of ileus 3
• The EAST guideline specifically states: "we cannot recommend for or against the use of metoclopramide to hasten the resolution of ileus" based on low-level evidence showing no benefit 3
• A 2001 prospective observational study found identical time to first bowel movement in patients receiving metoclopramide versus controls (4.8 vs 4.7 days, p=0.93), with no difference in ICU or hospital length of stay 4
• A 1991 randomized, double-blind study demonstrated that metoclopramide 20 mg IV three times daily did not reduce the duration of postoperative colonic paralysis compared with placebo 5

Mechanism and Limitations

Why Metoclopramide Fails in Ileus

The FDA label indicates that metoclopramide "increases peristalsis of the duodenum and jejunum" but critically notes it has "little, if any, effect on the motility of the colon" 6, 7. Since postoperative ileus predominantly affects the colon (which can remain paralyzed for 3-5 days postoperatively while the small bowel recovers in 12-24 hours), metoclopramide's mechanism of action does not address the primary site of dysfunction.

Safety Concerns

• The European Medicines Agency recommends against long-term use due to risks of extrapyramidal side effects and potentially irreversible tardive dyskinesia 1
• These neurological complications can occur even with short-term use and are particularly concerning given the lack of efficacy 1

What Actually Works for Ileus

Strongly Recommended Interventions

• Early enteral nutrition (EEN) is the only intervention with strong evidence: The EAST guideline meta-analysis of 32 randomized controlled trials showed EEN facilitates return of normal bowel function, achieves enteral nutrition goals faster, and reduces hospital length of stay 3
• Mid-thoracic epidural analgesia helps prevent postoperative ileus 1
• Avoidance of fluid overloading is critical, as excessive fluid administration worsens ileus 1
• Avoidance of nasogastric decompression unless specifically indicated 1
• Chewing gum has shown positive effects on postoperative duration of ileus and can be recommended 1

When to Suspect Alternative Diagnoses

Before attributing high output or delayed bowel function to simple ileus, exclude 2:

• Intra-abdominal sepsis
• Partial or intermittent bowel obstruction
• Infectious enteritis (Clostridium, Salmonella)
• Recurrent underlying disease (Crohn's disease, radiation enteritis)
• Medication effects (sudden steroid or opiate withdrawal, or inadvertent administration of prokinetics like metoclopramide)

Clinical Bottom Line

Do not use metoclopramide for ileus. Instead, focus on early enteral nutrition, appropriate fluid management, multimodal analgesia with epidural techniques when feasible, and supportive care while allowing time for spontaneous resolution 1, 3. The drug offers no benefit for this indication and exposes patients to unnecessary neurological risks.