What is the recommended IV dose of metoclopramide (Metoclopramide) for a patient with Chronic Kidney Disease (CKD) grade 5?

Metoclopramide IV Dosing in CKD Grade 5

For patients with CKD grade 5 (creatinine clearance <15 mL/min), initiate metoclopramide IV at approximately 5 mg (half the standard 10 mg dose) administered slowly over 1-2 minutes, with subsequent doses adjusted based on clinical efficacy and safety. 1

Dose Reduction Rationale

• Metoclopramide is principally excreted through the kidneys, making dose reduction essential in severe renal impairment to prevent drug accumulation and toxicity 1
• The FDA label explicitly states that therapy should be initiated at approximately one-half the recommended dosage when creatinine clearance is below 40 mL/min 1
• CKD grade 5 represents creatinine clearance <15 mL/min, which falls well below this 40 mL/min threshold and necessitates the 50% dose reduction 1

Specific Dosing Recommendations by Indication

For Diabetic Gastroparesis

• Start with 5 mg IV (half of the standard 10 mg dose) administered slowly over 1-2 minutes 1
• May administer intramuscularly or intravenously depending on symptom severity 1
• Treatment may continue up to 10 days before transitioning to oral therapy if symptoms improve 1

For Chemotherapy-Induced Nausea/Vomiting

• Reduce the standard dose by 50%: use 1 mg/kg (instead of 2 mg/kg) for highly emetogenic regimens, or 0.5 mg/kg (instead of 1 mg/kg) for less emetogenic regimens 1
• Administer as slow IV infusion over at least 15 minutes 1
• Dilute doses exceeding 5 mg in 50 mL of parenteral solution 1

For Postoperative Nausea/Vomiting

• Use 5 mg IM or IV (half of the standard 10 mg dose) near the end of surgery 1
• The standard 20 mg dose option should be reduced to 10 mg in CKD grade 5 1

For Small Bowel Intubation or Radiological Examination

• Administer 5 mg IV (half of the standard 10 mg dose) as a single dose over 1-2 minutes 1

Critical Safety Considerations

• Monitor for extrapyramidal reactions and sedation, which may be more pronounced with reduced drug clearance in severe CKD 1
• The elimination half-life of metoclopramide increases from 5-6 hours in normal renal function to significantly longer durations as creatinine clearance decreases 1
• Metoclopramide undergoes minimal hepatic metabolism, so dose adjustment is primarily driven by renal function rather than liver disease 1

Dose Titration Strategy

• Begin with the 50% reduced dose as outlined above 1
• Adjust upward or downward based on clinical efficacy and safety considerations, but maintain caution given the reduced clearance 1
• The linear kinetics of metoclopramide remain intact even in renal impairment, though clearance is substantially reduced 1

Comparative Efficacy in Uremia

• Research demonstrates that ondansetron (8 mg IV) is approximately twice as effective as metoclopramide (10 mg IV) for uremia-induced nausea and vomiting 2
• If metoclopramide proves inadequate at the reduced dose, consider switching to ondansetron rather than escalating metoclopramide dose in CKD grade 5 patients 2, 3

Dialysis Considerations

• Metoclopramide is dialyzable, though the FDA label provides limited specific guidance on post-dialysis dosing 1
• Standard doses of metoclopramide (≤0.2 mg/kg) do not antagonize renal effects of low-dose dopamine in critically ill patients, should concurrent therapy be necessary 4

Common Pitfalls to Avoid

• Do not use standard 10 mg doses without dose reduction in CKD grade 5, as this leads to drug accumulation 1
• Avoid assuming hepatic metabolism compensates for reduced renal clearance—metoclopramide relies primarily on renal elimination 1
• Do not extend dosing intervals as the primary adjustment strategy; the FDA recommends reducing individual doses while maintaining standard intervals 1