metoclopramide hydrochloride anhydrous: clinical use

Prescribing considerations

• Use should be short term and persistent vomiting warrants reassessment for an underlying cause.
• Children have a higher risk of acute extrapyramidal reactions; paediatric licensed uses are restricted and second line.
• Renal impairment, severe hepatic impairment and frailty require treatment review because exposure may increase.
• Assess neurological and cardiac risk, interacting medicines and electrolyte abnormalities before injectable use.

Contraindications and cautions

• Gastrointestinal haemorrhage, mechanical obstruction or perforation where increased motility would be hazardous.
• Phaeochromocytoma or suspected phaeochromocytoma.
• Epilepsy, Parkinson's disease, or previous metoclopramide- or neuroleptic-induced tardive dyskinesia.
• Concurrent levodopa or dopamine-agonist treatment.
• Previous metoclopramide-associated methaemoglobinaemia or NADH cytochrome-b5 deficiency.
• Children younger than 1 year.
• Hypersensitivity to metoclopramide or product excipients.

Monitoring

• Stop promptly if acute dystonia, dyskinesia, akathisia or other extrapyramidal symptoms occur.
• Monitor for neuroleptic malignant syndrome and persistent tardive dyskinesia.
• During intravenous use, consider blood pressure, heart rate, conduction risk and electrolyte status.
• Monitor digoxin or ciclosporin concentrations where clinically indicated.
• If used during breastfeeding, monitor the infant for sedation, feeding difficulty, gastrointestinal disturbance and unusual movements.

Clinical pharmacology

Metoclopramide is principally a central dopamine D2 antagonist, with 5-HT3 antagonism and 5-HT4 agonism. Its peripheral cholinergic effects accelerate gastric emptying and increase lower oesophageal sphincter tone. Clearance falls substantially in severe renal impairment, and accumulation may occur in cirrhosis.

Formulation and product differences

• The oral product is a clear, lemon-flavoured solution supplied with a graduated oral syringe.
• The injectable product is a clear sterile solution for intravenous or intramuscular administration.
• The selected injection contains sodium metabisulphite, which can rarely cause hypersensitivity reactions or bronchospasm.
• Intravenous injection requires slow administration because rapid delivery increases cardiovascular and neurological adverse-effect risk.

Oral solution

Route: Oral

Strengths: 5 mg/5 mL

Injection

Route: Parenteral

Strengths: 5 mg/mL