What is the recommended dose of domperidone (antiemetic and prokinetic agent) for adults?

Domperidone Dosing for Adults

The recommended starting dose of domperidone for adults is 10 mg three times daily, with a maximum dose of 20 mg three to four times daily (maximum 80 mg/day), though doses above 10 mg TID should be avoided when possible due to cardiac safety concerns. 1

Standard Dosing Protocol

• Starting dose: 10 mg orally three times daily 1
• Maximum dose: 20 mg three to four times daily 1, 2
• Typical therapeutic range: 40-80 mg/day divided into 3-4 doses 2, 3

Clinical Context and Applications

Domperidone is effective for multiple indications:

• Gastroparesis (diabetic or idiopathic) - improves gastric emptying and reduces symptoms 1, 2
• Chemotherapy-induced nausea and vomiting - typically dosed at 20 mg 3-4 times daily 1
• Functional dyspepsia and early satiety 1
• Refractory nausea and vomiting when added to standard antiemetic regimens 1

Critical Safety Considerations

Cardiovascular risks are the primary concern with domperidone:

• QT prolongation and risk of sudden cardiac death increase significantly with doses >30 mg/day 1, 4
• The safety index is only ~2.5, which is 12-fold below the accepted minimum 4
• Population studies show domperidone increases odds ratio for sudden cardiac death to 2.8 (range 1.53-6.21) 4

Absolute contraindications: 5

• Pre-existing QT prolongation
• Electrolyte abnormalities (hypokalemia, hypomagnesemia)
• Concurrent use of QT-prolonging medications
• Gastrointestinal obstruction

Monitoring Requirements

• ECG monitoring is warranted, particularly for long-term therapy or in patients with cardiac risk factors 1, 6
• Regular QTc monitoring via ECG is particularly important for therapy beyond several weeks 6

Duration of Treatment

• Maximum duration: Should not exceed 12 weeks for long-term use due to cumulative cardiac risks 6
• The British Society of Gastroenterology explicitly states domperidone should no longer be used long-term for chronic gastrointestinal motility disorders 1
• Despite this, some studies report safe use up to 12 years in selected patients with careful monitoring 2, 7

Dose Titration Strategy

Start conservatively and escalate cautiously:

1. Begin at 10 mg three times daily 1
2. Assess response at 2-3 months 3
3. If inadequate response and no cardiac concerns, may increase to 20 mg three times daily 1
4. Avoid escalation beyond 80 mg/day total due to sharply increased cardiac risk 6, 4

Clinical Efficacy Data

In a large single-center cohort of 115 gastroparesis patients:

• 69% reported symptom improvement on average dose of 36 mg/day 3
• Side effects occurred in 38% but only 12% required discontinuation 3
• Most common improvements: postprandial fullness, nausea, vomiting, and stomach fullness 3

Advantages Over Metoclopramide

Domperidone is preferred for extended therapy due to: 1

• Lower risk of extrapyramidal side effects (dystonia, akathisia, tardive dyskinesia)
• Does not readily cross blood-brain barrier 1
• Better tolerability profile for long-term use 2
• Preferred in Parkinson's disease patients 1

Common Pitfalls to Avoid

• Do not exceed 10 mg TID without compelling indication - cardiac risk increases sharply above 30 mg/day 1, 4
• Do not use long-term (>12 weeks) without regular cardiac monitoring 6
• Do not combine with other QT-prolonging medications without cardiology consultation 5
• Do not use in elderly patients (>60 years) at doses >30 mg/day - significantly increased arrhythmia risk 1

Alternative Options

If domperidone is unavailable, contraindicated, or ineffective: 1

• Metoclopramide: 5-20 mg three to four times daily (higher neurological risk)
• Ondansetron: 4-8 mg two to three times daily
• Prochlorperazine: 5-10 mg four times daily