Reglan Dosing in Peritoneal Dialysis Patients
Recommended Dose
For patients on nightly peritoneal dialysis with creatinine clearance below 40 mL/min, initiate metoclopramide (Reglan) at approximately one-half the standard recommended dosage, which translates to 5 mg rather than the standard 10 mg dose. 1
Dosing Algorithm
Start with 5 mg administered orally or intravenously (if severe symptoms require parenteral therapy), as the FDA label explicitly states that therapy should be initiated at approximately one-half the recommended dosage when creatinine clearance is below 40 mL/min 1
Titrate cautiously based on clinical efficacy and safety considerations—the dose may be increased or decreased as appropriate after assessing response 1
Timing considerations: Unlike hemodialysis where post-dialysis administration is preferred, peritoneal dialysis is continuous, so specific timing relative to dialysis exchanges is not critical 2, 3
Critical Rationale
Metoclopramide is excreted principally through the kidneys, making dose reduction mandatory in renal impairment 1
Peritoneal dialysis removes substantially less drug than hemodialysis, so supplemental dosing after dialysis exchanges is not necessary 2
However, because peritoneal dialysis provides continuous clearance (especially nightly automated peritoneal dialysis), cumulative drug removal occurs over time, justifying the reduced maintenance dose 2
The drug undergoes minimal hepatic metabolism except for simple conjugation, so the primary concern is renal excretion 1
Practical Implementation
For diabetic gastroparesis: Begin with 5 mg orally three times daily (rather than the standard 10 mg), taken 30 minutes before meals and at bedtime 1
For severe symptoms requiring IV therapy: Administer 5 mg slowly over 1-2 minutes (rather than the standard 10 mg) 1
Duration: Metoclopramide is not intended for long-term use—oral preparations are recommended for 4-12 weeks maximum, and parenteral use should be limited to 1-2 days 4
Safety Monitoring
Watch for extrapyramidal symptoms, which occur more frequently with high dosages or prolonged use—these are particularly concerning in dialysis patients who may have altered drug clearance 4
Monitor for common adverse effects including restlessness, drowsiness, fatigue, and lassitude, which may be more pronounced in patients with reduced clearance 4
Have diphenhydramine 50 mg available for intramuscular injection if acute dystonic reactions occur 1
Critical Pitfall to Avoid
Do not use standard 10 mg dosing in peritoneal dialysis patients—the FDA label is explicit that dose reduction is required when creatinine clearance falls below 40 mL/min, which applies to all dialysis patients 1. Starting at full dose risks drug accumulation and increased adverse effects, particularly extrapyramidal reactions 1, 4.