What is the recommended dose of metoclopramide (Reglan) for a patient with impaired renal function undergoing dialysis?

Metoclopramide (Reglan) Dosing in Dialysis Patients

For patients on hemodialysis, metoclopramide should be initiated at approximately 5 mg once daily (50% of the standard 10 mg dose), administered after dialysis sessions. 1

FDA-Approved Dosing Recommendations

The FDA package insert provides clear guidance for renal impairment:

• Creatinine clearance <40 mL/min: Initiate therapy at approximately one-half the recommended dosage 1
• The standard adult dose is 10 mg, so dialysis patients should start at 5 mg 1
• Dosage may be increased or decreased based on clinical efficacy and safety considerations 1

Pharmacokinetic Rationale

The dose reduction is necessary because metoclopramide is principally excreted through the kidneys, and both renal and nonrenal clearance are significantly impaired in renal dysfunction. 1, 2

Key pharmacokinetic considerations:

• Renal clearance accounts for ≤21% of total plasma clearance, but nonrenal clearance is also reduced in patients with renal impairment 2
• Plasma clearance correlates directly with creatinine clearance 2
• The elimination half-life is prolonged in renal dysfunction 2

Hemodialysis-Specific Considerations

Hemodialysis removes relatively small amounts of metoclopramide, so supplemental dosing after dialysis is generally not required. 2

• Metoclopramide losses during hemodialysis are small compared to total body stores 2
• Compensatory dosage increases are probably unnecessary for most patients 2
• Hemodialysis is unlikely to be effective in metoclopramide overdose 2

Timing of Administration

When possible, administer once-daily medications after dialysis sessions to optimize drug exposure and facilitate directly observed therapy. 3

This approach:

• Prevents drug removal during the dialysis session
• Ensures consistent plasma concentrations
• Simplifies medication adherence

Dosing Algorithm

1. Start low: Begin with 5 mg once daily (50% dose reduction) 1
2. Time appropriately: Administer after dialysis on dialysis days 3
3. Monitor closely: Assess for efficacy (gastroparesis symptom relief) and safety (extrapyramidal symptoms, tardive dyskinesia) 1
4. Titrate cautiously: May increase dose gradually if needed, but maintain awareness that reduced clearance increases cumulation risk 2

Critical Safety Considerations

The reduced plasma clearance in dialysis patients means maintenance doses must be reduced to avoid drug accumulation and toxicity. 2

Common pitfalls to avoid:

• Do not use standard 10 mg dosing: This will lead to excessive accumulation 1, 2
• Do not assume dialysis removes significant drug: Unlike some medications, metoclopramide is poorly dialyzed 2
• Monitor for neurological adverse effects: Extrapyramidal symptoms and tardive dyskinesia risk may be increased with accumulation 1
• Avoid chronic use when possible: Metoclopramide carries FDA warnings about tardive dyskinesia with prolonged use, which may be exacerbated in renal impairment 1

Special Populations

For patients with hepatic impairment and renal dysfunction:

• Metoclopramide undergoes minimal hepatic metabolism (simple conjugation only) 1
• Safe use has been described in patients with advanced liver disease whose renal function was normal 1
• In combined hepatic-renal impairment, maintain the 50% dose reduction and monitor closely 1