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Drug Reference

metoclopramide

prokinetic antiemetic· Brands: Reglan, Maxolon, Primperan, Clopamon, MetozolvIMIVPOSC

Mechanism of action
Metoclopramide is a dopamine D2 receptor antagonist and a 5-HT4 receptor agonist, with additional 5-HT3 receptor antagonist activity. It increases gastrointestinal motility by enhancing cholinergic activity and has central antiemetic effects by blocking dopamine receptors in the chemoreceptor trigger zone.
Pharmacokinetics
After oral administration, metoclopramide is well absorbed, with a bioavailability of about 70-80%. Peak plasma concentrations occur within 1-2 hours. It is partially metabolised in the liver, mainly by CYP2D6, and the elimination half-life is approximately 5-6 hours. Renal excretion is the primary route for unchanged drug and metabolites, so dose adjustment is needed in renal impairment.
Indications & dosing

Nausea and vomiting (including chemotherapy-induced)

Short-term use up to 5 days; also given IV/IM at same dose.

  • adult · PO: 10 mg TDS · Short-term use up to 5 days; also given IV/IM at same dose.

Postoperative nausea and vomiting

Administer at end of surgery; may repeat after 6 hours if needed.

  • adult · IV: 10 mg PRN · Administer at end of surgery; may repeat after 6 hours if needed.

Diabetic gastroparesis

Take 30 min before meals; short-term use only (2-8 weeks).

  • adult · PO: 10 mg TDS · Take 30 min before meals; short-term use only (2-8 weeks).

Acute migraine (adjunct to analgesic)off-label

Off-label in some regions; may also be given PO.

  • adult · IV: 10 mg Single dose · Off-label in some regions; may also be given PO.

Nausea and vomiting (children)

Not recommended under 1 year; max 10 mg per dose; max daily 0.3 mg/kg.

  • pediatric · IV: 0.1–0.2 mg/kg TDS · Not recommended under 1 year; max 10 mg per dose; max daily 0.3 mg/kg.
Contraindications & precautions
  • Gastrointestinal obstruction, perforation, or haemorrhage · Metoclopramide increases gastrointestinal motility, which could exacerbate these conditions.
  • Phaeochromocytoma · Risk of hypertensive crisis due to catecholamine release.
  • Hypersensitivity to metoclopramide · Includes any component of the formulation.
  • History of drug-induced extrapyramidal symptoms · Risk of recurrence of extrapyramidal symptoms.
  • Parkinson's disease · May worsen motor symptoms; alternative antiemetic preferred.
  • Epilepsy · May increase seizure frequency.
  • Reduce dose in renal impairment and consider in hepatic impairment, as accumulation increases adverse effects.
  • Use with caution in elderly patients, as they are more susceptible to extrapyramidal symptoms.
  • Avoid use in children unless clearly indicated, as the risk of extrapyramidal reactions is higher.
  • Caution in patients with epilepsy, as metoclopramide may lower the seizure threshold.
  • Monitor for signs of extrapyramidal symptoms, particularly during long-term use; discontinue if they occur.
  • Avoid concurrent use with other dopamine antagonists and serotonergic drugs to reduce risk of additive effects.
Adverse effects
  • Extrapyramidal symptoms (dystonia, akathisia, parkinsonism)serious
  • Tardive dyskinesiaserious
  • Neuroleptic malignant syndromeserious
  • Hyperprolactinaemia (galactorrhoea, gynaecomastia)
  • Drowsiness
  • Diarrhoea
  • QT interval prolongationserious
  • Headache
Interactions
  • co-beneldopacontraindicatedDo not prescribe metoclopramide to patients taking co-beneldopa. If antiemetic treatment is required, consider using an alternative antiemetic such as domperidone, which does not cross the blood-brain barrier and is less likely to worsen Parkinson's disease. Alternatively, other antiemetics such as cyclizine may be considered, but always consult current prescribing guidance and specialist advice. Monitor for any deterioration in motor function if an interaction is suspected.
Renal & hepatic adjustment
  • eGFR 60–300: No dosage adjustment required.
  • eGFR 30–59: Reduce dose to 50% of the usual adult dose.
  • eGFR 0–29: Reduce dose to 25% of the usual adult dose.
  • Hepatic impairment (mild): No dosage adjustment required, but use with caution.
  • Hepatic impairment (moderate): Use with caution; consider reducing the dose.
  • Hepatic impairment (severe): Avoid use in severe hepatic impairment. (avoid)
Monitoring, pregnancy & toxicity
  • Extrapyramidal symptoms (dystonia, parkinsonism) · During treatment, especially in the first 48 hours
  • Akathisia · With each dose adjustment
  • Prolactin levels if symptoms of hyperprolactinaemia occur · As clinically indicated
  • Psychiatric symptoms (e.g. depression, anxiety) · During treatment
  • Pregnancy: Metoclopramide is considered safe to use during pregnancy when clinically indicated, particularly for hyperemesis gravidarum. Use the lowest effective dose for the shortest possible duration, especially during the first trimester.
  • Toxicity: Acute dystonia: sudden muscle spasms, facial grimacing, oculogyric crisis. · Stop the drug; administer an anticholinergic (e.g. procyclidine 5 mg IV or diphenhydramine 10-20 mg IV/IM) for acute relief.
  • Toxicity: Akathisia: restlessness and an uncontrollable urge to move. · Stop the drug; a benzodiazepine (e.g. diazepam) may be used for short-term symptomatic relief.
  • Toxicity: Tardive dyskinesia: involuntary repetitive movements, especially facial, after prolonged treatment. · Stop the drug immediately; this is often irreversible. Seek specialist advice; consider switching to another antiemetic.
  • Toxicity: Neuroleptic malignant syndrome: hyperthermia, rigidity, autonomic instability, altered consciousness. · Stop the drug; provide supportive care and cool the patient. Specialist management with dantrolene or bromocriptine may be required.
Clinical notes
Metoclopramide is used for nausea and vomiting, particularly in postoperative and chemotherapy settings, and for gastro-oesophageal reflux disease and diabetic gastroparesis. It may cause extrapyramidal reactions, especially in the young and elderly, and tardive dyskinesia with prolonged use. The dose should be limited to the lowest effective dose for the shortest duration. It is contraindicated in phaeochromocytoma, bowel obstruction, and epilepsy.

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BNF; local formulary