Metoclopramide (Maxeran) Dosing for Ileus
Metoclopramide should generally be avoided in ileus, as it is contraindicated in mechanical obstruction and has limited evidence of efficacy in postoperative ileus. However, when used cautiously after ruling out mechanical obstruction, the typical dose is 10 mg IV every 6-8 hours 1, 2.
Critical Safety Considerations
- Mechanical obstruction must be ruled out before administering any prokinetic agent like metoclopramide 3
- Prokinetic agents and opioids should be avoided in the setting of ileus as they can worsen bowel dysmotility 3
- The FDA-approved indications for metoclopramide do not include ileus treatment 1, 2
Dosing Regimens When Used Off-Label
Standard IV Dosing
- 10 mg IV administered slowly over 1-2 minutes every 6-8 hours 1, 2
- Some sources suggest 10-20 mg PO four times daily for gastroparesis-type symptoms, though this is for constipation management rather than true ileus 3
Renal Adjustment
- In patients with creatinine clearance below 40 mL/min, initiate therapy at approximately one-half the recommended dosage 1, 2
Evidence Quality and Clinical Context
The evidence for metoclopramide in ileus is weak and contradictory:
- Two prospective studies found no significant benefit of metoclopramide for postoperative ileus, with no reduction in time to first bowel movement or length of stay 4, 5
- Animal studies showed reversal of decreased gastrointestinal activity with metoclopramide 0.4 mg/kg IV four times daily 6
- Case reports describe successful use in drug-induced ileus (methamphetamine, vincristine) 7, 8
Alternative Approach for Severe Cases
In fulminant C. difficile infection with ileus (a specific clinical scenario), guidelines recommend:
- Vancomycin 500 mg orally four times daily PLUS 500 mg rectally every 6 hours
- Metronidazole 500 mg IV every 8 hours as adjunctive therapy (not metoclopramide) 9
Clinical Pitfall
The most common error is using metoclopramide without adequately excluding mechanical obstruction, which represents an absolute contraindication 3. Always obtain imaging and clinical assessment before initiating any prokinetic therapy.