Metoclopramide

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What it isD2 and 5-HT3 antagonist; prokinetic for gastroparesis and GERD, and an antiemetic adjunct in migraine.

Why this oneIt combines antiemetic action with accelerated gastric emptying, which ondansetron does not.

What limits itTardive dyskinesia risk rises with duration. Acute dystonia is prominent in younger patients; avoid in bowel obstruction.

FDA-approved for

gastroparesis/GERD (~1979)

Off-label

migraine (adjunct)
lactation

FDA label

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BOXED WARNING Tardive dyskinesia, a potentially irreversible movement disorder; risk rises with duration and cumulative dose; limit treatment to ≤12 weeks.

FDA dosing	Population	Start	Target	Max
Symptomatic documented GERD (failed conventional therapy)	Adult	10–15 mg QID (30 min before meals + bedtime); or up to 20 mg PRN before provoking situation		60 mg/day; ≤12 weeks
Acute/recurrent diabetic gastroparesis	Adult	10 mg QID (30 min before meals + bedtime)		40 mg/day; avoid >12 weeks

Renal CrCl ≤60 mL/min (incl. ESRD/dialysis): reduce dosage

Hepatic Child-Pugh B or C: reduce dosage; Child-Pugh A: no adjustment

Instructions

Administer 30 minutes before each meal and at bedtime
Use shortest duration; reassess need; max 12 weeks
CYP2D6 poor metabolizers or strong CYP2D6 inhibitors: reduce dosage
Elderly: start 5 mg QID and titrate

Contraindications

History of tardive dyskinesia or dystonic reaction to metoclopramide
When GI motility stimulation is dangerous (GI hemorrhage, mechanical obstruction, perforation)
Pheochromocytoma or catecholamine-releasing paragangliomas
Epilepsy

Cautions

Tardive dyskinesia, other EPS/parkinsonism/akathisia
Neuroleptic malignant syndrome
Depression and suicidal ideation
MAOIs due to risk of serotonin syndrome
Fluid retention/volume overload in cirrhosis or CHF
Hyperprolactinemia
Impairs ability to drive/operate machinery

Adverse reactions

Restlessness
Drowsiness
Fatigue and lassitude
Extrapyramidal symptoms / acute dystonia
Insomnia, headache, dizziness
Depression

Pregnancy Studies do not report increased risk of adverse pregnancy outcomes; monitor neonate for EPS and methemoglobinemia if given at delivery

Lactation Present in human milk in variable amounts; monitor infant for GI effects, EPS, methemoglobinemia

⚠ BOXED WARNING

Tardive dyskinesia

Cost, est. cash$20–$1,500/dose or month

Generic entry1985

Classes and tags

Clinical profile

Therapeutic safety burden1 / 4

Overdose danger1 / 4

Weight-gain liability0 / 4

Sedation liability1 / 4

QT / Torsades0 / 4

Direct muscarinic antagonism0 / 4

Embryofetal risk1 / 4

Legacy pregnancy categoryB

Defining liabilityGenerally tolerated at therapeutic doses; clinically important risks are agent-specific and increase with interactions or organ impairment.