Reglan
Reglan
[reg´lan]metoclopramide hydrochloride
Pharmacologic class: Dopamine antagonist
Therapeutic class: Antiemetic, GI stimulant
Pregnancy risk category B
FDA Box Warning
• Drug can cause tardive dyskinesia, a serious movement disorder that's often irreversible. Risk of developing tardive dyskinesia increases with duration of treatment and total cumulative dose.
• Discontinue drug in patients who develop signs or symptoms of tardive dyskinesia, which has no known treatment. In some patients, signs and symptoms may lessen or resolve after drug is stopped.
• Avoid using metoclopramide for longer than 12 weeks except in rare cases in which potential benefit outweighs risk of developing tardive dyskinesia.
Action
Blocks dopamine receptors by disrupting CNS chemoreceptor trigger zone, increasing peristalsis and promoting gastric emptying
Availability
Injection: 5 mg/ml
Solution: 5 mg/5 ml
Solution (concentrated): 10 mg/ml
Tablets: 5 mg, 10 mg
Tablets (orally disintegrating): 5 mg, 10 mg
Indications and dosages
➣ To prevent chemotherapy-induced vomiting
Adults: 1 to 2 mg/kg I.V. 30 minutes before chemotherapy, then q 2 hours for two doses, then q 3 hours for three additional doses
➣ To facilitate small-bowel intubation; radiologic examination when delayed gastric emptying interferes
Adults and children older than age 14: 10 mg I.V. as a single dose
Children ages 6 to 14: 2.5 to 5 mg I.V. as a single dose
Children younger than age 6: 0.1 mg/kg I.V. as a single dose
➣ Diabetic gastroparesis
Adults: 10 mg P.O. 30 minutes before meals and at bedtime for 2 to 8 weeks. If patient can't tolerate P.O. doses, give same dosage I.V. or I.M.
➣ Gastroesophageal reflux
Adults: 10 to 15 mg P.O. 30 minutes before meals and at bedtime for up to 12 weeks. For prevention, single dose of 20 mg (some patients may respond to doses as small as 5 mg).
➣ Prevention of postoperative nausea and vomiting
Adults: 10 to 20 mg I.M. near end of surgical procedure. Repeat dose q 4 to 6 hours, as needed.
Dosage adjustment
• Renal impairment
Off-label uses
• Hiccups
Contraindications
• Hypersensitivity to drug
• Pheochromocytoma
• Parkinson's disease
• Suspected GI obstruction, perforation, or hemorrhage
• History of seizure disorders
Precautions
Use cautiously in:
• diabetes mellitus, renal dysfunction
• history of depression
• elderly patients
• pregnant or breastfeeding patients
• children.
Administration
• Mix oral solution with water, juice, carbonated beverage, or semisolid food (such as applesauce or pudding) just before administration.
• Remove orally disintegrating tablets with dry hands immediately before administering. After removing, place tablet on patient's tongue, where it will dissolve in approximately 1 minute. Tell patient to swallow saliva.
• Give I.M. or direct I.V. without further dilution.
• Administer low doses (10 mg or less) by direct I.V. injection slowly over 2 minutes. (Rapid injection may cause intense anxiety and restlessness followed by drowsiness.)
• For I.V. infusion, dilute with 50 ml of 5% dextrose in 0.9% sodium chloride solution, 5% dextrose in 0.45% sodium chloride solution, or lactated Ringer's solution. Infuse over at least 15 minutes.
Adverse reactions
CNS: drowsiness, restlessness, anxiety, depression, irritability, fatigue, lassitude, insomnia, tardive dyskinesia, parkinsonian-like reactions, extrapyramidal reactions, akathisia, dystonia
CV: hypertension, hypotension, arrhythmias, neuroleptic malignant syndrome
GI: nausea, constipation, diarrhea, dry mouth
GU: gynecomastia
Interactions
Drug-drug. Anticholinergics, opioids: antagonism of metoclopramide's GI motility effect
Antidepressants, antihistamines, other CNS depressants (such as opioids, sedative-hypnotics): additive CNS depression
Cimetidine, digoxin: decreased blood levels of these drugs
General anesthestics: exaggerated hypotension
Haloperidol, phenothiazines: increased risk of extrapyramidal reactions
Levodopa: decreased metoclopramide efficacy
MAO inhibitors: increased catecholamine release
Drug-diagnostic tests. Aldosterone, prolactin: increased levels
Drug-behaviors. Alcohol use: increased blood alcohol level, increased CNS depression
Patient monitoring
• Monitor blood pressure during I.V. administration.
• Stay alert for depression and other adverse CNS effects.
See Watch for extrapyramidal reactions, which usually occur within first 24 to 48 hours of therapy. To reverse these symptoms, give diphenhydramine 50 mg I.M. or benztropine 1 to 2 mg I.M., as prescribed.
• Check for development of parkinsonian-like symptoms, which may occur within first 6 months of therapy and usually subside within 2 to 3 months after withdrawal.
See With long-term use, assess patient for tardive dyskinesia and discontinue drug if signs or symptoms of tardive dyskinesia develop. Avoid treatment for longer than 12 weeks in all but rare cases in which therapeutic benefit outweighs risk of developing tardive dyskinesia.
See Monitor patient closely for signs and symptoms of neuroleptic malignant syndrome (hyperthermia, muscle rigidity, altered consciousness, and evidence of autonomic instability [irregular pulse or blood pressure, tachycardia, diaphoresis, and cardiac arrhythmias]); immediately discontinue drug if these symptoms occur.
• In diabetic patient, stay alert for gastric stasis. Insulin dosage may need to be adjusted.
Patient teaching
• Tell patient to take 30 minutes before meals.
• Tell patient taking orally disintegrating tablets to remove tablet with dry hands immediately before use. Instruct patient to place tablet on tongue, where it will dissolve in approximately 1 minute, and then swallow saliva.
See Instruct patient to report involuntary movements of face, eyes, or limbs; muscle rigidity; altered consciousness; irregular pulse or blood pressure; rapid or irregular heartbeats; or excessive sweating.
• Caution patient to avoid driving and other hazardous activities until drug's effects are known.
• As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs, tests, and behaviors mentioned above.
metoclopramide
(met-oh-kloe-pra-mide) metoclopramide,Metonia
(trade name),Metozolv ODT
(trade name),Reglan
(trade name)Classification
Therapeutic: antiemeticsIndications
Action
Therapeutic effects
Pharmacokinetics
Time/action profile (effects on peristalsis)
| ROUTE | ONSET | PEAK | DURATION |
|---|---|---|---|
| PO | 30–60 min | unknown | 1–2 hr |
| IM | 10–15 min | unknown | 1–2 hr |
| IV | 1–3 min | immediate | 1–2 hr |
Contraindications/Precautions
Adverse Reactions/Side Effects
Central nervous system
- drowsiness (most frequent)
- extrapyramidal reactions (most frequent)
- restlessness (most frequent)
- neuroleptic malignant syndrome (life-threatening)
- anxiety
- depression
- irritability
- tardive dyskinesia
Cardiovascular
- arrhythmias (supraventricular tachycardia, bradycardia)
- hypertension
- hypotension
Gastrointestinal
- constipation
- diarrhea
- dry mouth
- nausea
Endocrinologic
- gynecomastia
Hematologic
- methemoglobinemia
- neutropenia
- leukopenia
- agranulocytosis
Interactions
Drug-Drug interaction
Additive CNS depression with other CNS depressants, including alcohol, antidepressants, antihistamines, opioid analgesics, and sedative/hypnotics.May ↑ absorption and risk of toxicity from cyclosporine.May affect the GI absorption of other orally administered drugs as a result of effect on GI motility.May exaggerate hypotension during general anesthesia.↑ risk of extrapyramidal reactions with agents such as haloperidol or phenothiazines.Opioids and anticholinergics may antagonize the GI effects of metoclopramide.Use cautiously with MAO inhibitors (causes release of catecholamines).May ↑ neuromuscular blockade from succinylcholine.May ↓ effectiveness of levodopa.May ↑ tacrolimus serum levels.Route/Dosage
Prevention of Chemotherapy-Induced VomitingAvailability (generic available)
Nursing implications
Nursing assessment
- Assessfor nausea, vomiting, abdominal distention, and bowel sounds before and after administration.
- Assess for extrapyramidal side effects (parkinsonian—difficulty speaking or swallowing, loss of balance control, pill rolling, mask-like face, shuffling gait, rigidity, tremors; and dystonic—muscle spasms, twisting motions, twitching, inability to move eyes, weakness of arms or legs) periodically throughout course of therapy. May occur weeks to months after initiation of therapy and are reversible on discontinuation. Dystonic reactions may occur within minutes of IV infusion and stop within 24 hr of discontinuation of metoclopramide. May be treated with 50 mg of IM diphenhydramine or diphenhydramine 1 mg/kg IV may be administered prophylactically 15 min before metoclopramide IV infusion.
- Monitor for tardive dyskinesia (uncontrolled rhythmic movement of mouth, face, and extremities; lip smacking or puckering; puffing of cheeks; uncontrolled chewing; rapid or worm-like movements of tongue). Usually occurs after a year or more of continued therapy; risk of tardive dyskinesia increases with total cumulative dose. Report immediately and discontinue metoclopramide; may be irreversible.
- Monitor for neuroleptic malignant syndrome (hyperthermia, muscle rigidity, altered consciousness, irregular pulse or BP, tachycardia, and diaphoresis).
- Assess for signs of depression periodically throughout therapy.
- Lab Test Considerations: May alter hepatic function test results.
- May cause ↑ serum prolactin and aldosterone concentrations.
Potential Nursing Diagnoses
Imbalanced nutrition: less than body requirements (Indications)Risk for injury (Side Effects)
Implementation
- Oral: Administer doses 30 min before meals and at bedtime.
- Do not to remove orally disintegrating tablets from the bottle until just prior to dosing. Remove tablet from bottle with dry hands and immediately place on tongue to disintegrate and swallow with saliva. Tablet typically disintegrates in 1–1.5 minutes. Administration with liquid is not necessary.
- Intramuscular: For prevention of postoperative nausea and vomiting, inject IM near the end of surgery.
Intravenous Administration
- Administer IV dose 30 min before administration of chemotherapeutic agent.
- Rate: Doses may be given slowly over 1–2 min. Rapid administration causes a transient but intense feeling of anxiety and restlessness followed by drowsiness.
- Intermittent Infusion: Diluent: May be diluted for IV infusion in 50 mL of D5W, 0.9% NaCl, D5/0.45% NaCl, Ringer’s solution, or LR. Diluted solution is stable for 48 hr if protected from light or 24 hr under normal light.Concentration: May dilute to 0.2 mg/mL or give undiluted at 5 mg/mL.
- Rate: Infuse slowly (maximum rate 5 mg/min) over at least 15–30 min.
- Y-Site Compatibility: aldesleukin, alemtuzumab, alfentanil, amifostine, amikacin, aminophylline, amphotericin B lipid complex, anidulafungin, argatroban, ascorbic acid, atropine, azathioprine, aztreonam, benztropine, bivalirudin, bleomycin, bumetanide, buprenorphine, butorphanol, calcium chloride, calcium gluconate, carboplatin, caspofungin, cefazolin, cefoperazone, cefotaxime, cefotetan, cefoxitin, ceftaroline, ceftazidime, ceftriaxone, cefuroxime, chloramphenicol, chlorpromazine, ciprofloxacin, cisatracurium, cisplatin, cladribine, clindamycin, cyanocobalamin, cyclophosphamide, cyclosporine, cytarabine, dactinomycin, daptomycin, dexamethasone, dexmedetomidine, digoxin, diltiazem, diphenhydramine, dobutamine, docetaxel, dopamine, doripenem, doxapram, doxorubicin hydrochloride, doxycyline, droperidol, enalaprilat, ephedrine, epinephrine, epirubicin, epoetin alfa, eptifibatide, ertapenam, erythromycin, esmolol, etoposide, etoposide phosphate, famotidine, fenoldopam, fentanyl, filgrastim, fluconazole, fludarabine, folic acid, foscarnet, gemcitabine, gentamicin, glycopyrrolate, granisetron, heparin, hetastarch, hydrocortisone sodium succinate, hydromorphone, idarubicin, ifosfamide, imipenem/cilastatin, indomethacin, insulin, irinotecan, isoproterenol, ketamine, ketorolac, labetalol, leucovorin, levofloxacin, lidocaine, linezolid, lorazepam, magnesium sulfate, mannitol, mechlorethamine, melphalan, meperidine, meropenem, methadone, methotrexate, methoxamine, methyldopate, methylprednisolone, metoprolol, metronidazole, midazolam, milrinone, mitomycin, mitoxantrone, morphine, multiple vitamins, mycophenolate, nafcillin, nalbuphine, naloxone, nesiritide, nitroglycerin, nitroprusside, norepinephrine, octreotide, ondansetron, oxacillin, oxaliplatin, oxytocin, paclitaxel, palonosetron, pamidronate, pancuronium, pantoprazole, papaverine, pemetrexed, penicillin G, pentamidine, pentazocine, pentobarbital, phenobarbital, phentolamine, phenylephrine, phytonadione, piperacillin/tazobactam, potassium acetate, potassium chloride, procainamide, prochlorperazine, promethazine, propranolol, protamine, pyridoxine, quinupristin/dalfopristin, ranitidine, remifentanil, rituximab, rocuronium, sargramostim, sodium acetate, sodium bicarbonate, streptokinase, succinylcholine, sufentanil, tacrolimus, telavancin, teniposide, theophylline, thiamine, thiotepa, ticarcillin/clavulanate, tigecycline, tirofiban, tobramycin, tolazoline, topotecan, trastuzumab, trimetaphan, vancomycin, vasopressin, vecuronium, verapamil, vinblastine, vincristine, vinorelbine, voriconazole, zidovudine, zoledronic acid
- Y-Site Incompatibility: amphotericin B cholesteryl, amphotericin B colloidal, amphotericin B liposome, amsacrine, carmustine, cefepime, dantrolene, diazepam, diazoxide, doxorubicin liposome, ganciclovir, phenytoin, propofol, trimethoprim/sulfamethoxazole
Patient/Family Teaching
- Instruct patient to take metoclopramide as directed. Take missed doses as soon as remembered if not almost time for next dose. Advise patient to read the Medication Guide before starting therapy and with each Rx refill in case of changes.
- Pediatric: Unintentional overdose has been reported in infants and children with the use of metoclopramide oral solution. Teach parents how to accurately read labels and administer medication.
- May cause drowsiness. Caution patient to avoid driving or other activities requiring alertness until response to medication is known.
- Advise patient to avoid concurrent use of alcohol and other CNS depressants while taking this medication.
- Inform patient of risk of extrapyramidal symptoms, tardive dyskinesia, and neuroleptic malignant syndrome. Advise patient to notify health care professional immediately if involuntary or repetitive movements of eyes, face, or limbs occur.
Evaluation/Desired Outcomes
- Prevention or relief of nausea and vomiting.
- Decreased symptoms of gastric stasis.
- Facilitation of small bowel intubation.
- Decreased symptoms of esophageal reflux.
- Metoclopramide should not be used for more than 12 wk due to risk of tardive dyskinesia.