metoclopramide (Rx)

Brand and Other Names:Reglan, Metozolv ODT
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Dosing & Uses

AdultPediatric

Dosage Forms & Strengths

injectable solution

  • 5mg/mL

syrup

  • 5mg/5mL
  • 10mg/10mL

tablet

  • 5mg
  • 10mg

Dispersible tablets

  • 5mg
  • 10mg
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Chemotherapy-Induced Nausea & Vomiting

2 mg/kg IV (infused over at least 15 minutes) 30 minutes before chemotherapy, then repeated 2 more times q2hr (after initial dose) 

Vomiting suppressed: Decrease to 1 mg/kg IV q3hr for 3 doses  

Vomiting not suppressed: Continue same dose q3hr for 3 doses

Diabetic Gastroparesis

10 mg IV/IM/PO q6hr 30 minutes before meals and at bedtime; use injectable dosing only if severe symptoms are present

Small Bowel Intubation/Radiologic Examination of Upper GI Tract

10 mg IV over 1-2 minutes

Gastroesophageal Reflux Disease

10-15 mg PO q6hr 30 minutes before meals and at bedtime; not to exceed 80 mg/day

Postoperative Nausea & Vomiting (Off-label)

10-20 mg IM administered near end of procedure; may be repeated postoperatively q4-6hr PRN

Dosing Modifications

Renal impairment: CrCl <40 mL/min, decrease dose by 50%; CrCl <10 mL/min, decrease dose by 75%

Dosage Forms & Strengths

injectable solution

  • 5mg/mL

syrup

  • 5mg/5mL
  • 10mg/10mL

tablets

  • 5mg
  • 10mg

Dispersible tablets

  • 5mg
  • 10mg
more...

Small Bowel Intubation/Radiologic Examination of Upper GI Tract

<6 years old: 0.1 mg/kg IV over 1-2 minutes 

6-14 years old: 2.5-5 mg IV over 1-2 minutes

≥14 years old: 10 mg IV over 1-2 minutes

Gastroesophageal Reflux Disease (Off-label)

Neonate: 0.15 mg/kg IV q6hr  

Infant: 0.1 mg/kg IV/IM/PO q6-8hr 30 minutes before meals and at bedtime  

Not to exceed 0.3-0.75 mg/kg/day  

Diabetic Gastroparesis (Off-label)

<6 years old: 0.1 mg/kg PO q8hr; not to exceed 0.1 mg/kg 

≥6 years old: 0.5 mg/kg/day PO divided q8hr

Postoperative Nausea & Vomiting (Off-label)

0.1-2 mg/kg IV q6-8hr PRN 

Chemotherapy-Induced Nausea & Vomiting (Off-label)

1-2 mg/kg IV (infused over at least 15 minutes) 30 minutes before chemotherapy; repeat q2-4hr; pretreatment with diphenhydramine decreases risk of extrapyramidal adverse effects  

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Interactions

Interaction Checker

and metoclopramide

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    No Interactions Found
    Interactions Found

    Contraindicated

      Serious - Use Alternative

        Significant - Monitor Closely

          Minor

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            Adverse Effects

            >10%

            Extrapyramidal symptoms (dystonic reactions in 25% of young adults 18-30 years old)

            1-10%

            Fatigue (2-10%)

            Restlessness (10%)

            Sedation (10%)

            Headache (4-5%)

            Dizziness (1-4%)

            Somnolence (2-3%)

            Frequency Not Defined

            Diarrhea

            Nausea

            Galactorrhea

            Gynecomastia

            Impotence

            Menstrual disorders

            Neuroleptic malignant syndrome

            Hematologic abnormalities

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            Warnings

            Black Box Warnings

            May cause tardive dyskinesia (often irreversible)

            Risk of developing tardive dyskinesia increases with treatment duration and total cumulative dose

            Discontinue with signs or symptoms of tardive dyskinesia

            No known treatment exists for tardive dyskinesia

            Symptoms may lessen or resolve after metoclopramide treatment is stopped

            Do not administer for longer than 12 weeks, except in rare cases where therapeutic benefit is thought to outweigh risk of tardive dyskinesia

            Contraindications

            Hypersensitivity to metoclopramide or procainamide

            History of tardive dyskinesia (TD) or a dystonic reaction to metoclopramide

            When stimulation of gastrointestinal motility might be dangerous (e.g., in the presence of gastrointestinal hemorrhage, mechanical obstruction, or perforation)

            Presence of pheochromocytoma or other catecholamine-releasing paragangliomas

            Patients with history of epilepsy

            Other drugs causing extrapyramidal symptoms (eg, phenothiazines, butyrophenones)

            Cautions

            Mental depression reported; use with caution in patients with history of mental illness

            Use with caution or avoid in parkinson disease patients; may have increased risk of extrapyramidal symptoms

            Use with caution after GI anastomosis or closure; promotility agents reported to increase pressure in suture lines

            Use caution in patients with hypertension, CHF, renal impairment, cirrhosis

            Use caution in patients who are at risk of fluid overload

            Metoclopramide may cause a potentially fatal symptom complex called neuroleptic malignant syndrome (NMS). NMS has been reported in association with metoclopramide overdosage and concomitant treatment with another drug associated with NMS; discontinue therapy immediately if symptoms occur

            Can cause tardive dyskinesia (see Black Box Warnings), especially in elderly; discontinue if signs or symptoms of tardive dyskinesia develop (metoclopramide itself may completely or partially suppress these manifestations); tardive dyskinesia may persist even after drug is discontinued

            As with other dopamine D2 receptor antagonists, metoclopramide elevates prolactin levels

            Galactorrhea, amenorrhea, gynecomastia, and impotence reported with prolactin-elevating drugs, including metoclopramide; hyperprolactinemia may potentially stimulate prolactin-dependent breast cancer; however, some clinical studies and epidemiology studies have not shown an association between administration of dopamine D2 receptor antagonists and tumorigenesis in humans

            May impair mental and/or physical abilities required for performance of hazardous tasks such as operating machinery or driving a motor vehicle; concomitant use of central nervous system (CNS) depressants or drugs associated with EPS may increase this effect (e.g., alcohol, sedatives, hypnotics, opiates, and anxiolytics); avoid drug or the interacting drug, depending on importance of drug to the patient

            Diphenhydramine 50 mg IM can be given for extrapyramidal symptoms

            Pseudoparkisonism (eg, tremor, rigidity) may occur within 6 months of therapy; reversible within 2-3 months of discontinuing therapy

            Metoclopramide IV administration associated with catecholamine release; use caution in patients with hypertension

            Hypertensive crisis reported in patients with undiagnosed pheochromocytoma; discontinue therapy immediately with any sudden increase in blood pressure during therapy

            May cause QT prolongation and torsades de pointes in some patients with heart failure patients that also have renal impairment; data on healthy males have failed to show similar effects; implicatiosn unclear; use caution in cardiovascular disease

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            Pregnancy & Lactation

            Pregnancy

            Published studies, including retrospective cohort studies, national registry studies, and meta-analyses, do not report an increased risk of adverse pregnancy-related outcomes with use of metoclopramide during pregnancy. There are potential risks to neonate following exposure in utero to metoclopramide during delivery; in animal reproduction studies, no adverse developmental effects were observed with oral administration of metoclopramide to pregnant rats and rabbits at exposures about 6 and 12 times the maximum recommended human dose (MRHD)

            Metoclopramide crosses the placental barrier and may cause extrapyramidal signs and methemoglobinemia in neonates with maternal administration during delivery; monitor neonates for extrapyramidal signs

            Lactation

            Limited published data report the presence of metoclopramide in human milk in variable amounts; breastfed infants exposed to metoclopramide have experienced gastrointestinal adverse reactions, including intestinal discomfort and increased intestinal gas formation; metoclopramide elevates prolactin levels; however, published data are not adequate to support drug effects on milk production; developmental and health benefits of breastfeeding should be considered along with mother’s clinical need for therapy and any potential adverse effects on breastfed child from therapy or from underlying maternal condition

            Monitor breastfeeding neonates because metoclopramide may cause extrapyramidal signs (dystonias) and methemoglobinemia

            Pregnancy Categories

            A:Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.

            B:May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.

            C:Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.

            D:Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.

            X:Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.

            NA:Information not available.

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            Pharmacology

            Mechanism of Action

            Blocks dopamine receptors (at high dose) and serotonin receptors in chemoreceptor trigger zone of CNS; and sensitizes tissues to acetylcholine; increases upper GI motility but not secretions; increases lower esophageal sphincter tone

            Absorption

            Bioavailability: IM, 74-96%; PO, 65-95%

            Onset: 1-3 min (IV, ); 10-15 min (IM); 30-60 min (PO)

            Duration: 1-2 hr regardless of route

            Peak serum time: IV, 15 min; PO, 60-120 min

            Distribution

            Protein bound: 30-40%

            Vd: 3.5 L/kg

            Metabolism

            Metabolized by liver

            Metabolites: Metoclopramide glucuronides, metoclopramide sulfates, aminoacetic acid (inactive)

            Elimination

            Half-life (IV/IM): 5-6hr (adults); 4 hr (children)

            Dialyzable: Not significant; dose adjustment after dialysis unnecessary

            Total body clearance: 0.53-0.55 L/hr/kg (prolonged in neonates as compared with adults)

            Excretion: Primarily urine (85%)

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            Administration

            IV Incompatibilities

            Solution: D5W (at high drug concentration)

            Additive: Dexamethasone sodium phosphate with lorazepam and diphenhydramine, erythromycin lactobionate, floxacillin, fluorouracil, furosemide

            Syringe: Ampicillin, calcium gluconate, chloramphenicol sodium succinate, furosemide, methotrexate, penicillin G potassium, sodium bicarbonate

            Y-site: Allopurinol, amphotericin B cholesteryl sulfate, amsacrine, cefepime, doxorubicin liposomal, furosemide, propofol

            IV Compatibilities

            Additive: Cimetidine, clindamycin, meperidine, meropenem, morphine sulphate, potassium chloride, verapamil

            Syringe (partial list): Butorphanol, chlorpromazine, cisplatin, cyclophosphamide, cytarabine, dexamethasone, dimenhydrinate, diphenhydramine, doxorubicin, fentanyl, fentanyl with midazolam, fluorouracil, heparin, hydromorphone, hydroxyzine, insulin, lidocaine, magnesium sulfate, meperidine, midazolam, morphine, ondansetron, pentazocine, prochlorperazine, promethazine, ranitidine, vitamins B and C

            Y-site (partial list): Aztreonam, bivalirudin, ciprofloxacin, cisplatin, cytarabine, diltiazem, docetaxel, doxorubicin, famotidine, fentanyl, fluconazole, fluorouracil, heparin, hydromorphone, linezolid, meperidine, morphine sulfate, ondansetron, quinupristin-dalfopristin, zidovudine

            IV Administration

            NS is preferred diluent because drug is most stable in this solution

            Dose ≤10 mg: IV push over 1-2 minutes

            Dose >10 mg: Dilute in 50 mL D5W or NS, and infuse over at least 15 minutes

            Protect from light

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            Formulary

            FormularyPatient Discounts

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            The above information is provided for general informational and educational purposes only. Individual plans may vary and formulary information changes. Contact the applicable plan provider for the most current information.

            Tier Description
            1 This drug is available at the lowest co-pay. Most commonly, these are generic drugs.
            2 This drug is available at a middle level co-pay. Most commonly, these are "preferred" (on formulary) brand drugs.
            3 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs.
            4 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            5 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            6 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            NC NOT COVERED – Drugs that are not covered by the plan.
            Code Definition
            PA Prior Authorization
            Drugs that require prior authorization. This restriction requires that specific clinical criteria be met prior to the approval of the prescription.
            QL Quantity Limits
            Drugs that have quantity limits associated with each prescription. This restriction typically limits the quantity of the drug that will be covered.
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            Drugs that have step therapy associated with each prescription. This restriction typically requires that certain criteria be met prior to approval for the prescription.
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            Drugs that have restrictions other than prior authorization, quantity limits, and step therapy associated with each prescription.
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            Medscape prescription drug monographs are based on FDA-approved labeling information, unless otherwise noted, combined with additional data derived from primary medical literature.