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Dyspepsia - unidentified cause - Management
What issues should I consider before prescribing metoclopramide?

  • Metoclopramide is licensed for the following conditions:
    • Restoring normal co-ordination and tone to the upper digestive tract.
    • Relieving symptoms of gastro-duodenal dysfunction (e.g. dyspepsia, heartburn, flatulence, sickness) in condition such as: peptic ulcer, duodenitis, reflux oesophagitis, hiatus hernia, gastritis.
  • Contraindications:
    • Metoclopramide should not be used in those with gastrointestinal obstruction, perforation or haemorrhage.
    • Avoid using metoclopramide during the first three to four days following gastrointestinal surgery as vigorous muscular contractions may not help healing.
    • Avoid using the drug in those with phaeochromocytoma as it may induce an acute hypertensive response.
  • Dose:
    • Adults 20 years and over: 10 mg three times daily.
    • For the elderly: avoid prolonged therapy to minimize the risk of adverse reactions.
    • Reduce dose in those with significant degrees of renal or hepatic impairment.
  • Drug interaction:
    • The risk of extrapyramidal adverse effect is increased if metoclopramide is prescribed to those on neuroleptics such as the phenothiazines.
    • Metoclopramide (a dopamine antagonist) should be used with care in association with other drugs acting at central dopamine receptors (e.g. levodopa, bromocriptine and pergolide).
  • Adverse reactions:
    • Extrapyramidal adverse reactions, usually of the dystonic type, have been reported.
      • The majority of reactions occur within 36 hours of starting treatment and the effects usually disappear within 24 hours of withdrawal of the drug.
    • Neuroleptic malignant syndrome is very rare. This syndrome is potentially fatal and must be treated urgently. Metoclopramide should be stopped immediately if this syndrome occurs (hyperpyrexia, altered consciousness, muscle rigidity and autonomic instability with elevated levels of creatine phosphokinase).
    • Tardive dyskinesia has been reported during prolonged treatment in a small number of mainly elderly patients. People on prolonged treatment should be regularly reviewed.
    • Raised serum prolactin levels have been observed during metoclopramide therapy: this may result in galactorrhoea, irregular periods and gynaecomastia.

[ABPI Medicines Compendium, 2008b]

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