Metoclopramide Removal During Hemodialysis
Metoclopramide (Reglan) removal during a 4-hour hemodialysis session is minimal and clinically insignificant, with losses representing only a small fraction of total body drug stores—supplemental dosing after dialysis is unnecessary.
Evidence for Minimal Dialytic Clearance
The most direct evidence comes from a pharmacokinetic study specifically examining metoclopramide clearance during hemodialysis 1:
- Metoclopramide losses from hemodialysis were relatively small compared to estimates of total body metoclopramide stores 1
- The study concluded that compensatory dosage increases are probably unnecessary for most patients undergoing hemodialysis 1
- Furthermore, hemodialysis is not likely to be effective in metoclopramide overdose, underscoring the limited dialytic removal 1
Pharmacokinetic Rationale
The limited dialyzability of metoclopramide relates to its clearance characteristics 1:
- Renal clearance accounts for ≤21% of total plasma clearance, regardless of renal function 1
- Nonrenal clearance (hepatic metabolism) is the predominant elimination pathway, accounting for most drug removal 1
- In patients with renal impairment, creatinine clearance correlates with metoclopramide plasma clearance, but the reduction in nonrenal clearance accounts for most of the decrease in total clearance 1
Clinical Implications for Dosing
No supplemental dose is needed after a 4-hour dialysis session 1. However, maintenance doses should be reduced in dialysis patients due to decreased total body clearance, not because of dialytic removal 1.
Important Caveats
- While hemodialysis removes minimal metoclopramide, peritoneal dialysis removes even less medication than hemodialysis 2
- The quantity of drugs removed during peritoneal dialysis is substantially lower than during hemodialysis, making supplemental dosing completely unnecessary 2
- Metoclopramide can cause serious, long-lasting adverse effects even with short-term, low-dose use, including extrapyramidal reactions that may persist for months 3
Practical Answer
While no specific percentage is provided in the literature, the removal is described as "relatively small" and insufficient to warrant dose replacement 1. The clinical takeaway is clear: do not give supplemental metoclopramide after dialysis, as the amount removed is negligible compared to body stores 1.