metoclopramide

metoclopramide

(met oh kloe pra' mide)

Apo-Metoclop (CAN), Maxolon, Nu-Metoclopramide (CAN), Octamide PFS, Reclomide, Reglan

Pregnancy Category B

Drug classes

GI stimulant

Antiemetic

Dopaminergic blocker

Therapeutic actions

Stimulates motility of upper GI tract without stimulating gastric, biliary, or pancreatic secretions; appears to sensitize tissues to action of acetylcholine; relaxes pyloric sphincter, which, when combined with effects on motility, accelerates gastric emptying and intestinal transit; little effect on gallbladder or colon motility; increases lower esophageal sphincter pressure; has sedative properties; induces release of prolactin.

Indications

·        Relief of symptoms of acute and recurrent diabetic gastroparesis

·        Short-term therapy (4–12 wk) for adults with symptomatic gastroesophageal reflux who fail to respond to conventional therapy

·        Parenteral: Prevention of nausea and vomiting associated with emetogenic cancer chemotherapy

·        Prophylaxis of postoperative nausea and vomiting when nasogastric suction is undesirable

·        Single-dose parenteral use: Facilitation of small-bowel intubation when tube does not pass the pylorus with conventional maneuvers

·        Single-dose parenteral use: Stimulation of gastric emptying and intestinal transit of barium when delayed emptying interferes with radiologic exam of the stomach or small intestine

·        Unlabeled uses: Improvement of lactation (doses of 30–45 mg/day); treatment of nausea and vomiting of a variety of etiologies: Emesis during pregnancy and labor, gastric ulcer, anorexia nervosa

Contraindications and cautions

·        Contraindicated with allergy to metoclopramide; GI hemorrhage, mechanical obstruction or perforation; pheochromocytoma (may cause hypertensive crisis); epilepsy.

·        Use cautiously with previously detected breast cancer (one third of such tumors are prolactin dependent); lactation, pregnancy.

Available forms

Tablets—5, 10 mg; concentrated solution—10 mg/mL; injection—5 mg/mL

Dosages

ADULTS

·        Relief of symptoms of gastroparesis: 10 mg PO 30 min before each meal and hs for 2–8 wk. If symptoms are severe, initiate therapy with IM or IV administration for up to 10 days until symptoms subside.

·        Symptomatic gastroesophageal reflux: 10–15 mg PO up to 4 times/day 30 min before meals and hs. If symptoms occur only at certain times or in relation to specific stimuli, single doses of 20 mg may be preferable; guide therapy by endoscopic results. Do not use longer than 12 wk.

·        Prevention of postoperative nausea and vomiting: 10–20 mg IM at the end of surgery.

·        Prevention of chemotherapy-induced emesis: Dilute and give by IV infusion over not less than 15 min. Give first dose 30 min before chemotherapy; repeat q 2 hr for 2 doses, then q 3 hr for 3 doses. The initial two doses should be 2 mg/kg for highly emetogenic drugs (cisplatin, dacarbazine); 1 mg/kg may suffice for other chemotherapeutic agents. If extrapyramidal symptoms occur, administer 50 mg of diphenhydramine IM.

·        Facilitation of small bowel intubation, gastric emptying: 10 mg (2 mL) by direct IV injection over 1–2 min.

PEDIATRIC PATIENTS

·        Facilitation of intubation, gastric emptying:
< 6 yr: 0.1 mg/kg by direct IV injection over 1–2 min.
6–14 yr: 2.5–5 mg by direct IV injection over 1–2 min.

Pharmacokinetics

Route	Onset	Peak	Duration
Oral	30–60 min	60–90 min	1–2 hr
IM	10–15 min	60–90 min	1–2 hr
IV	1–3 min	60–90 min	1–2 hr

Metabolism: Hepatic; T_1/2: 5–6 hr

Distribution: Crosses placenta; enters breast milk

Excretion: Urine

IV facts

Preparation: Dilute dose in 50 mL of a parenteral solution (dextrose 5% in water, sodium chloride injection, dextrose 5% in 0.45% sodium chloride, Ringer's injection, or lactated Ringer's injection). May be stored for up to 48 hr if protected from light or up to 24 hr under normal light.

Infusion: Give direct IV doses slowly (over 1–2 min); give infusions over at least 15 min.

Incompatibilities: Do not mix with solutions containing chloramphenicol, sodium bicarbonate, cisplatin, erythromycin.

Y-site incompatibility: Do not give with furosemide.

Adverse effects

·        CNS: Restlessness, drowsiness, fatigue, lassitude, insomnia, extrapyramidal reactions, parkinsonism-like reactions, akathisia, dystonia, myoclonus, dizziness, anxiety

·        CV: Transient hypertension

·        GI: Nausea, diarrhea

Interactions

Drug-drug

·        Decreased absorption of digoxin from the stomach

·        Increased toxic and immunosuppressive effects of cyclosporine

Nursing considerations

Assessment

·        History: Allergy to metoclopramide, GI hemorrhage, mechanical obstruction or perforation, pheochromocytoma, epilepsy, lactation, previously detected breast cancer

·        Physical: Orientation, reflexes, affect; P, BP; bowel sounds, normal output; EEG

Interventions

·        Monitor BP carefully during IV administration.

·        Monitor for extrapyramidal reactions, and consult physician if they occur.

·        Monitor diabetic patients, arrange for alteration in insulin dose or timing if diabetic control is compromised by alterations in timing of food absorption.

·        WARNING: Keep diphenhydramine injection readily available in case extrapyramidal reactions occur (50 mg IM).

·        WARNING: Have phentolamine readily available in case of hypertensive crisis (most likely to occur with undiagnosed pheochromocytoma).

Teaching points

·        Take this drug exactly as prescribed.

·        Do not use alcohol, sleep remedies, sedatives; serious sedation could occur.

·        You may experience these side effects: Drowsiness, dizziness (do not drive or perform other tasks that require alertness); restlessness, anxiety, depression, headache, insomnia (reversible); nausea, diarrhea.

·        Report involuntary movement of the face, eyes, or limbs, severe depression, severe diarrhea.

Adverse effects in Italic are most common; those in Bold are life-threatening.