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All About Metoclopramide (Reglan)

Numerous studies have shown that metoclopramide was the clear first choice of emergency physicians for treating gastritis. However, earlier this year, a randomized controlled trial of ondansetron (Zofran), metoclopramide, and a placebo, showed there was no statistically significant difference in the reduction of nausea severity between the three. Metoclopramide, however, has been shown to be better than a placebo for the treatment of migraine headaches.

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  Nauseating Evidence Part 2/3 (Metoclopramide)

What's the ideal dose? I typically see patients get a single 10 mg dose at my program (because thats all we carry;). It was interesting to see in this RCT of ondansetron, metoclopramide, and placebo, that they were receiving 20 mg in the metoclopramide arm. So I did a little digging to figure out what the ideal dose is. I was unable to find a study comparing various dosing regimens (let me know if you find one). I did find though recommendations by the FDA to deliver no more than 20mg in a single dose or 60mg within a 24 hour period. There does not appear to be any change in symptom relief or peak concentration time between 10 and 20mg. There was however prolonged duration of effects such as increased lower esophageal pressure (LESP) (5mg = 45 minutes vs 20mg = 2-3 hours). For my 20 minute helicopter ride.. 10 mg seems like the goldilocks number.

Articles of Interest

Tardive Dyskinesia in an Emergency Setting

The medications that are known to have the possibility to cause tardive dyskinesia include antipsychotic drugs, anticholinergic agents (ex. Procyclidine), antidepressants, antiemetics (ex. Metoclopramide), anticonvulsants, antihistamines...

The efficacy and safety of metoclopramide in relieving acute migraine attacks compared with other anti-migraine drugs: a systematic review and network meta-analysis of randomized controlled trials

All of these findings may consider metoclopramide to be one of the first-line treatments to decrease acute migraine attacks in the emergency department.

Akathisia

Recognized since the 1950s as a paradoxical increase in restlessness/agitation, akathisia most commonly results in response to first-generation antipsychotics such as haloperidol (Hodge 1959). It can present as an exacerbation of chronic medication use, or acutely in the ED. Acute Akathisia is most commonly seen in the ED as a side effect of drugs with D-2 receptor antagonism used to treat nausea or migraine:

emDocs Cases: Headache Management in the ED

One of the most common medications used in a “headache cocktail” is metoclopramide, an antidopaminergic and serotonin receptor antagonist, often administered 10 mg IV or IM.9-11,24,26,40-45 This medication has significant literature support, with one meta-analysis suggesting a NNT of 4 for pain reduction.43 Akathisia is a potential side effect, which can be reduced with slower rate of infusion.

Modern Headache Management: Best Practices Update

10, 20, and 40 mg of metoclopramide with diphenhydramine improve headaches to a similar degree, although adverse effects are also comparable. There is no "best dose".

Resources

StatPearls

Metoclopramide can cause tardive dyskinesia, a serious movement disorder. Tardive dyskinesia risk increases with the total treatment duration and total cumulative exposure. Therefore, avoid treatment with metoclopramide tablets for longer than 12 weeks.