Medications> Gastroparesis>

INDICATIONS

• Diabetic gastroparesis (PO and IV)
• Stimulation of gastric emptying and intestinal transit of barium in cases where delayed emptying interferes with radiological examination (IV).
• GERD (PO)
• Nausea/vomiting (post-op and chemotherapy induced)(IV)
• Small Bowel Intubation if tube does not pass the pylorus with conventional maneuvers (IV)

• Lactation induction
• Singultus (hiccups)
• Migraine
• Radiation sensitizer in combination with radiation therapy in the treatment of patients with non-small cell lung cancer (NSCLC)

MECHANISM

USUAL ADULT DOSING

• 10 mg PO, IV or IM four times per day, 30 minutes before meals and at bedtime for 2 to 8 weeks. Up to 10 days may be required before symptoms subside.

FORMS

*Prices represent cost per unit specified and are representative of "Average Wholesale Price" (AWP). AWP Prices were obtained and gathered by Lakshmi Vasist Pharm D using the Red Book, manufacturer's information, and the McKesson database.

^Dosage is indicated in mg unless otherwise noted.

DOSING IN SPECIAL POPULATIONS

• CrCl < 40 ml/min: initiate with 50% of normal dose, then titrate to effect

• No dosage adjustments are needed.

• Pregnancy category B. No impairment of fertility or significant harm to the fetus in animal studies. Limited clinical data on the safe use of metoclopramide for the treatment of hyperemesis gravidarum.

• Metoclopramide is distributed into breast milk. The American Academy of Pediatrics continues to recommend caution during the use of metoclopramide in breast-feeding secondary to the potential for CNS effects from the use of the drug.

ADVERSE DRUG REACTIONS

• Adverse CNS effects: Black Box Warning regarding the risk of tardive dyskinesia.

• Neurologic: Somnolence (oral, 2.1% to 10%; IV, up to 70% with high dose 1-2 mg/kg/dose)
• Fatigue

• Reversible extrapyramidal effects, pseudoparkinsonism (dose related occurs more commonly with doses >40 mg/d)
• Hyperprolactinemia, erectile dysfunction, menstrual irregularity
• Headache (4.2% to 5.2%)
• Gastrointestinal: Nausea and vomiting (association unclear).

• Neuroleptic malignant syndrome
• Insomnia, restlessness, and depression
• Hypotension, hypertension, AV block, sinus bradycardia, and supraventricular tachycardia (SVT).
• Hypersensitivity reaction

DRUG INTERACTIONS

• Posaconazole: may decrease posaconazole serum concentrations. Take posaconazole with a high fat meal and monitor for therapeutic efficacy.
• Venlafazine: may increase risk of serotonin syndrome, but this is rare. Monitor with co-administration.
• Sedatives, benzodiazepines, opiates: somnolence may be increased with metoclopramide co-administration.
• MAOI: use with close monitoring.
• Digoxin: digoxin serum concentration may be decreased. Monitor digoxin serum concentrations with metoclopramide co-administration.
• Dopamine agonist (e.g. ropinirole, amantadine, bromocriptine, levodopa, pergolide, and pramipexole): metoclopramide may antagonize dopamine agonist activities. Use with close monitoring.
• Cyclosporine and tacrolimus: Serum concentrations of cyclosporine and tacrolimus may be increased. Use with close therapeutic drug monitoring.

PHARMACOKINETIC

COMMENTS

• Short-term (2-8 weeks) use of metoclopramide can be considered for diabetic gastroparesis; however, somnolence can be problematic for some patients.
• Small prospective randomized studies in diabetic patients found improved gastric emptying time with the use of metoclopramide.

REFERENCES

RELATED MODULES

• Autonomic Neuropathy