Is Reglan (Metoclopramide) safe for a patient with coronary artery disease (CAD) status post (s/p) stent placement and atrial fibrillation (AFib) who is undergoing dialysis due to impaired renal function?

From the Guidelines

Reglan (metoclopramide) should be used with caution in patients with coronary artery disease (CAD) with stents, atrial fibrillation (AFib), and those on dialysis, due to potential risks and interactions with other medications, as well as the need for dose adjustment and close monitoring for side effects. For these complex patients, a reduced dose of 5 mg once or twice daily (rather than the standard 10 mg) is generally recommended, with close monitoring for side effects, as metoclopramide can potentially prolong the QT interval, which is particularly concerning for patients with AFib who may already be on medications affecting cardiac conduction 1. In patients with CAD and stents, the medication's effects on blood pressure and heart rate should be monitored. For dialysis patients, dose adjustment is necessary as metoclopramide is partially cleared by the kidneys, and these patients may have altered drug metabolism and increased sensitivity to side effects. Short-term use (less than 12 weeks) is strongly advised to minimize the risk of tardive dyskinesia. Before starting Reglan, potential drug interactions with the patient's existing medications for CAD and AFib should be evaluated by their healthcare provider, as combinations with certain antiarrhythmics or anticoagulants may require additional monitoring, as recommended by the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation 1.

Some key considerations for the management of patients with AFib, including those with CAD and on dialysis, include:

• The use of antithrombotic therapy based on shared decision making, discussion of risks of stroke and bleeding, and patient’s preferences 1
• The selection of antithrombotic therapy based on risk of thromboembolism, with the CHA2DS2-VASc score recommended to assess stroke risk 1
• The use of warfarin for mechanical heart valves and target INR intensity based on type and location of prosthesis, as well as the use of direct thrombin or factor Xa inhibitors in certain situations 1
• The evaluation of renal function before initiation of direct thrombin or factor Xa inhibitors, and reevaluation when clinically indicated and at least annually 1

It is essential to carefully evaluate the potential benefits and risks of using Reglan in patients with CAD, AFib, and those on dialysis, and to closely monitor these patients for any adverse effects or interactions with other medications.

From the FDA Drug Label

Use in Patients with Renal or Hepatic Impairment Since metoclopramide is excreted principally through the kidneys, in those patients whose creatinine clearance is below 40 mL/min, therapy should be initiated at approximately one-half the recommended dosage. Metoclopramide undergoes minimal hepatic metabolism, except for simple conjugation. Its safe use has been described in patients with advanced liver disease whose renal function was normal

The FDA drug label does not provide direct information about the use of metoclopramide in patients with coronary artery disease (CAD) status post (s/p) stent and atrial fibrillation (AFib) who are on dialysis. However, it does provide guidance on dosage adjustment for patients with renal impairment.

• Renal Impairment: The label recommends initiating therapy at approximately one-half the recommended dosage in patients with creatinine clearance below 40 mL/min.
• Dialysis: The label mentions that information regarding dialysis can be found in the OVERDOSAGE section, but it does not provide specific guidance on the use of metoclopramide in patients on dialysis.
• CAD s/p stent and AFib: There is no direct information in the label regarding the use of metoclopramide in patients with CAD s/p stent and AFib. Given the lack of direct information, no conclusion can be drawn about the safety of metoclopramide in this specific patient population 2, 2.

From the Research

Reglan Use in Patients with CAD, AFib, and Dialysis

• There is no direct evidence in the provided studies regarding the use of Reglan in patients with coronary artery disease (CAD), atrial fibrillation (AFib), and dialysis.
• However, the studies discuss antithrombotic therapy in patients with AFib undergoing coronary artery stenting, which may be relevant to patients with CAD and AFib 3, 4, 5, 6, 7.
• The use of anticoagulants and antiplatelet agents in patients with AFib and CAD is complex and requires careful consideration of the individual patient's risk factors and medical history 3, 4, 5, 7.
• In general, patients with AFib and CAD may require a combination of anticoagulant and antiplatelet therapy to reduce the risk of stroke and cardiovascular events, but this must be balanced against the increased risk of bleeding 3, 4, 5, 7.
• The choice of antithrombotic therapy in patients with AFib and CAD should be individualized based on the patient's specific risk factors and medical history, and may involve the use of oral anticoagulants, antiplatelet agents, or a combination of both 3, 4, 5, 7.