What is the treatment for Perinorm (metoclopramide)-associated facial palsy?

Treatment of Metoclopramide-Associated Facial Palsy

Metoclopramide-associated facial palsy should be treated by immediately discontinuing the offending medication, followed by oral corticosteroids (prednisolone 50 mg daily for 10 days or prednisone 60 mg daily for 5 days with a 5-day taper) initiated within 72 hours of symptom onset, combined with aggressive eye protection measures. 1, 2

Immediate Management Steps

1. Discontinue Metoclopramide

• Stop the causative agent immediately upon recognition of facial palsy, as drug-induced peripheral facial nerve palsy can resolve with discontinuation of the offending medication 3
• Blood pressure monitoring is essential if hypertension is present, as drug-induced hypertension can contribute to facial nerve palsy 3

2. Exclude Alternative Diagnoses

• Perform a thorough history and physical examination to exclude stroke (which spares the forehead), trauma, infection (Lyme disease, herpes zoster), tumor, or other identifiable causes before proceeding with treatment 1, 4
• Document function of all cranial nerves to exclude central causes or cranial polyneuritis 1, 4
• Routine laboratory testing and imaging are NOT recommended unless atypical features are present (bilateral involvement, other cranial nerve deficits, recurrence on same side, or no recovery after 3 months) 1, 2

Pharmacological Treatment

Corticosteroid Therapy (Primary Treatment)

• Initiate oral corticosteroids within 72 hours of symptom onset for patients 16 years and older 1, 2
• Recommended regimens:
  • Prednisolone 50 mg daily for 10 days, OR
  • Prednisone 60 mg daily for 5 days followed by 10 mg decrements daily for 5 days 1, 2, 5
• Evidence demonstrates 83% recovery at 3 months with prednisolone versus 63.6% with placebo, and 94.4% recovery at 9 months versus 81.6% with placebo 2
• Do NOT initiate steroids beyond 72 hours, as there is no evidence of benefit after this window 2

Antiviral Therapy Considerations

• Do NOT prescribe antiviral monotherapy alone, as it is ineffective 1, 2
• May consider adding oral antiviral therapy (valacyclovir or acyclovir) to corticosteroids within 72 hours if severe pain or complete paralysis is present, though the added benefit is minimal 2, 5
• Acyclovir 400 mg orally five times daily for 10 days can be used as an alternative to valacyclovir 2

Mandatory Eye Protection Protocol

Immediate Implementation

• Implement aggressive eye protection for all patients with impaired eye closure to prevent permanent corneal damage 1, 2

Specific Eye Protection Measures:

• Lubricating ophthalmic drops: Apply every 1-2 hours while awake 2
• Ophthalmic ointment: Apply at bedtime for sustained moisture retention 2
• Eye taping or patching: Use at night with careful instruction on proper technique to avoid corneal abrasion 2
• Sunglasses: Wear outdoors to protect against wind and foreign particles 2
• Moisture chambers: Consider polyethylene covers for severe cases 2

Urgent Ophthalmology Referral Indications:

• Complete inability to close the eye 2
• Eye pain, vision changes, redness, discharge, or foreign body sensation 2
• Signs of corneal exposure or damage 2

Follow-Up and Reassessment Algorithm

Mandatory Reassessment or Specialist Referral at:

• 3 months after symptom onset if incomplete facial recovery persists 1, 2
• Any point if new or worsening neurologic findings develop 1, 2
• Any point if ocular symptoms develop 1, 2

Expected Recovery Timeline:

• Most patients begin showing recovery within 2-3 weeks 2
• Complete recovery typically occurs within 3-4 months 2
• Patients with incomplete paralysis have up to 94% recovery rates 2
• Patients with complete paralysis have approximately 70% complete recovery rates within 6 months 2

Special Considerations for Drug-Induced Facial Palsy

Key Differences from Idiopathic Bell's Palsy:

• Drug-induced facial palsy may resolve more rapidly with discontinuation of the offending agent 3
• Monitor for resolution of associated drug-induced hypertension if present 3
• Consider gradual improvement as evidence that the medication was the causative factor 3

Common Pitfalls to Avoid

• Delaying corticosteroid treatment beyond 72 hours reduces effectiveness 2
• Using antiviral therapy alone is ineffective and delays appropriate treatment 1, 2
• Inadequate eye protection can lead to permanent corneal damage 2
• Failing to discontinue the causative medication may prevent resolution 3
• Improper eye taping technique can cause corneal abrasion 2
• Failing to refer at 3 months delays access to reconstructive options 2

Long-Term Management if Recovery Incomplete

Reconstructive Options (After 3 Months):

• Refer to facial nerve specialist or facial plastic surgeon for evaluation 2
• Static procedures: eyelid weights, brow lifts, static facial slings 2
• Dynamic procedures: nerve transfers, dynamic facial slings 2
• Tarsorrhaphy or eyelid weight implantation for persistent lagophthalmos 2

Psychological Support:

• Screen for depression in patients with persistent paralysis 2
• Address psychosocial dysfunction and quality of life issues 2