Reglan Dosing for Nightly Peritoneal Dialysis
For patients with end-stage renal disease on nightly peritoneal dialysis, initiate metoclopramide (Reglan) at 5 mg (half the standard dose) and administer it once daily or every other day, as metoclopramide is primarily renally excreted and requires dose reduction when creatinine clearance falls below 40 mL/min.
Dose Adjustment Based on FDA Labeling
- The FDA label explicitly states that for patients with creatinine clearance below 40 mL/min, therapy should be initiated at approximately one-half the recommended dosage 1
- The standard dose for diabetic gastroparesis is 10 mg IV/IM, so the adjusted starting dose would be 5 mg 1
- After initiating at the reduced dose, the dosage may be increased or decreased based on clinical efficacy and safety considerations 1
Peritoneal Dialysis-Specific Considerations
- Metoclopramide is minimally removed by peritoneal dialysis, unlike hemodialysis where supplemental dosing after dialysis sessions may be needed 2
- Drug clearance in peritoneal dialysis patients is substantially lower than in hemodialysis, so supplemental administration is not necessary 2
- For patients on nightly peritoneal dialysis (NIPD), the dosing should follow the same principles as continuous ambulatory peritoneal dialysis (CAPD), using approximately 50% of the standard dose 2
- The timing of administration does not need to be coordinated with dialysis exchanges, as drug removal during peritoneal dialysis is minimal 3
Practical Dosing Algorithm
Start with 5 mg once daily:
- Monitor for therapeutic response (improved gastric emptying, reduced nausea) 1
- Watch for adverse effects, particularly extrapyramidal symptoms and tardive dyskinesia 4
- If inadequate response after 2-3 days and no adverse effects, may cautiously increase to 5 mg twice daily 1
Consider extending dosing interval:
- For patients with minimal residual renal function, dosing every 48 hours (5 mg every other day) may be appropriate initially 2
- Patients with some preserved urine output may tolerate once-daily dosing better than anuric patients 2
Critical Safety Monitoring
- Extrapyramidal reactions are more common in renal impairment due to drug accumulation 1
- Keep diphenhydramine 50 mg available for acute dystonic reactions 1
- Limit duration of therapy to the shortest effective period, as tardive dyskinesia risk increases with prolonged use 4
- Reassess need for continued therapy regularly, as metoclopramide carries significant neurological risks in ESRD patients 4
Common Pitfall to Avoid
Do not use standard 10 mg doses without adjustment - this is the most frequent prescribing error in dialysis patients, as metoclopramide accumulates significantly when renal clearance is impaired 5. The reduced clearance in peritoneal dialysis patients, even with nightly exchanges, necessitates dose reduction from the outset 2.