Metoclopramide (Reglan)

Emergency & Prehospital

• Nausea and vomiting in adults: Treats the symptom, migraine-associated nausea included. EU-labeled. Off-label in the US, where ondansetron is the usual first choice.
• Acute migraine needing parenteral therapy: For migraine that needs a parenteral drug, IV metoclopramide is level B (should offer) in the American Headache Society (AHS) 2025 ED guideline. IV prochlorperazine is level A, and IV ketorolac is level B (off-label). Differs from FDA label: not labeled for migraine.

ED / ICU / Transport

• Acute or recurrent diabetic gastroparesis: Severe symptoms get IV or IM first, then oral therapy. FDA-labeled.
• Nausea and vomiting of pregnancy and hyperemesis gravidarum: A second-line antiemetic, alone or with others, per RCOG 2024 guidance. Off-label in the US.
• Postoperative nausea and vomiting (PONV) prophylaxis: Used when nasogastric suction is undesirable. FDA-labeled.
• Small-bowel tube placement: It gets a feeding or enteric tube past the pylorus when conventional maneuvers fail. Adults and children (FDA-labeled).
• Enteral feeding intolerance in critically ill adults: An alternative to IV erythromycin, the ESPEN 2023 first-line prokinetic. Use it alone or with erythromycin, once obstruction, perforation and severe distension are excluded (off-label).
• Radiologic examination: It speeds gastric emptying and barium transit when delayed emptying gets in the way of the study (FDA-labeled).
• Chemotherapy-induced nausea and vomiting (CINV) prophylaxis: The high-dose IV regimen is FDA-labeled, but it now sits outside routine practice. Current ASCO guidance builds prophylaxis on 5-HT3 antagonist, NK1 antagonist, dexamethasone and olanzapine combinations.

Other Uses

• Gastroesophageal reflux disease (GERD): Oral, for 4–12 weeks in adults who fail conventional therapy. FDA-labeled.
• Diabetic gastroparesis maintenance: Oral tablets or nasal spray. The total course stays at 12 weeks or less. FDA-labeled.

Every dose below comes from a cited label or guideline. Your agency protocol governs what gets stocked and what is allowed.

Available Forms

• Injection: Stocked by EDs and transport services. It comes as 5 mg/mL in a 2 mL (10 mg) single-dose vial, for IV or IM use only.
• Tablets: 5 mg and 10 mg; orally disintegrating tablets (ODT) and oral solution are also available.
• Nasal spray (Gimoti): Its own product, named in the Reglan label for adult diabetic gastroparesis. Not an acute-care product.

Adult Dosing

Pediatric Dosing

Weight-based dose checks: pediatric weight-based dosing.

Preparation & Administration

• IV push: Give 10 mg undiluted over at least 1–2 min (US labeling). EU labeling says at least 3 min. Push fast and the patient gets sudden, intense anxiety and restlessness first, then drowsiness.
• Infusion: Doses above 10 mg go in 50 mL (normal saline preferred) and run over at least 15 min. ED migraine trials gave 10 mg in 50 mL saline over 15 min.
• IM: inject undiluted.
• Light and inspection: keep vials in the carton; discard if discolored or particulate is seen. Diluted solutions keep 24 hr in normal light, or 48 hr protected from light.
• Interval: EU labeling keeps doses at least 6 hr apart, even after vomiting or a rejected oral dose. For children, NASEMSO allows one repeat, 20–30 min after the first dose if no relief.

Contraindications

• History of tardive dyskinesia (TD) or a dystonic reaction to metoclopramide
• Whenever increased GI motility could be dangerous: GI hemorrhage, mechanical obstruction or perforation
• Pheochromocytoma or other catecholamine-releasing paraganglioma: risk of hypertensive crisis
• Epilepsy: Seizures may get more frequent and severe.
• Hypersensitivity to metoclopramide: reactions include laryngeal and glossal angioedema and bronchospasm
• EU labeling adds: Parkinson disease; combination with levodopa or dopamine agonists; age under 1 year; prior methemoglobinemia with metoclopramide or NADH-cytochrome b5 reductase deficiency; the first 3–4 days after pyloroplasty or gut anastomosis; breastfeeding

Precautions

• Parkinson disease or other movement disorders: Avoid it. Dopamine blockade worsens parkinsonism.
• Cardiac conduction disease, bradycardia, QT prolongation, uncorrected electrolytes: IV doses have caused bradycardia, AV block, QT prolongation, torsades de pointes and cardiac arrest.
• Hypertension or MAOI therapy: IV metoclopramide releases catecholamines. US labeling advises avoiding the injection.
• Heart failure or cirrhosis: The aldosterone rise is brief, but it can still cause fluid retention and volume overload.
• History of depression: Depression, suicidal ideation and suicide are reported. Reglan tablet labeling (2026) says avoid use. Injection labeling says give it only if the expected benefit outweighs the risk.
• Older adults, diabetes, renal or hepatic impairment, CYP2D6 poor metabolizers: Higher levels and more TD risk. See Special Populations.

Hold / Reassess If

• Akathisia, dystonia or parkinsonism appears: stop and treat
• Rapid rise in blood pressure: stop
• New bradycardia, hypotension or AV block during IV dosing: stop and obtain a 12-lead ECG
• Fever with rigidity and altered mental status (possible neuroleptic malignant syndrome): stop all dopamine antagonists
• Any involuntary facial, tongue or limb movements: stop immediately (possible TD)

Common

• Drowsiness, fatigue, restlessness and lassitude: about 10% at 10 mg four times daily; drowsiness about 70% at 1–2 mg/kg CINV doses
• Akathisia: about 1 in 10 adults after 10–40 mg IV in an ED migraine trial, even with diphenhydramine co-administered
• Hypotension: common with IV dosing (EU labeling)
• Diarrhea
• Headache, dizziness, insomnia, confusion
• Transient flushing of the face and upper body after high IV doses
• Hyperprolactinemia with repeated use: galactorrhea, amenorrhea, gynecomastia, impotence

Serious / Life-Threatening

Overdose & Toxicity Management

• Signs: drowsiness, disorientation, confusion, hallucinations, extrapyramidal reactions, methemoglobinemia, neuroleptic malignant syndrome and cardiorespiratory arrest; deaths are reported.
• Immediate management: airway, breathing and circulation; continuous cardiac and respiratory monitoring; supportive care; call Poison Control (1-800-222-1222).
• Antidote: None specific. For dystonia, use diphenhydramine or benztropine in adults, or a benzodiazepine such as lorazepam or midazolam in children. Methylene blue treats methemoglobinemia unless the patient is G6PD deficient.
• Extracorporeal removal: Neither hemodialysis nor peritoneal dialysis removes significant amounts.

Clinically Significant Interactions

Faster gastric emptying changes how other oral drugs are absorbed. Digoxin, atovaquone, posaconazole oral suspension and fosfomycin get absorbed less. Cyclosporine, tacrolimus and sirolimus get absorbed more. Check levels where available.

IV Compatibility

• Diluents: normal saline (preferred), D5W, D5/0.45% saline, Ringer's or lactated Ringer's.
• Physically compatible admixtures (label): diphenhydramine, dexamethasone sodium phosphate, benztropine, heparin, lidocaine, potassium phosphate.
• Incompatible: sodium bicarbonate, cephalothin, chloramphenicol.
• Verify with an institutional compatibility resource.

• Pediatrics: In the US, children get the injection only as a single dose for small-bowel intubation, and tablets are not recommended. NASEMSO gives an antiemetic dose only at age over 2 yr and over 12 kg (see the Pediatric Dosing table). Children get dystonia and other EPS more often than adults. EU labeling allows it only as a second-line antiemetic from age 1 yr.
• Neonates: Avoid. Low NADH-cytochrome b5 reductase makes methemoglobinemia more likely. Maternal doses during delivery can also cause neonatal EPS and methemoglobinemia.
• Pregnancy: Published cohort, registry and meta-analysis studies report no increased risk of adverse pregnancy-related outcomes (Reglan tablet label, section 8.1). It crosses the placenta. Avoid it near delivery when possible. If you give it, monitor the newborn for EPS and methemoglobinemia. For nausea and vomiting of pregnancy and hyperemesis gravidarum, NASEMSO (p. 90) recommends metoclopramide 5–10 mg IV with diphenhydramine 25 mg IV over ondansetron in the first trimester. RCOG 2024 guidance rates it safe and effective. Still second line, because of EPS. If given IV, use a slow bolus (EU labeling: over at least 3 min).
• Lactation: It passes into milk. Infants receive less than 10% of the maternal weight-adjusted dose. Breastfed infants have had GI upset, so watch for dystonia and methemoglobinemia. Metoclopramide raises prolactin. Published data are not adequate to show an effect on milk production. US labeling weighs benefit against risk. EU labeling advises against use while breastfeeding.
• Older Adults: Older adults carry more TD risk, especially older women, along with parkinsonism and confusion from sedation. AGS Beers Criteria 2023 says avoid it, except for gastroparesis and for no more than 12 weeks. Avoid it in Parkinson disease. Use the lowest effective dose. Oral therapy starts at 5 mg four times daily.
• Renal Impairment: Exposure doubles at moderate to severe impairment. It is 3.5-fold in ESRD on dialysis. Half-life rises to about 10 hr (CrCl 10–50 mL/min) and 15 hr (CrCl under 10 mL/min). Injection, more than a single dose: CrCl 60 mL/min or less, give half the dose. ESRD (hemodialysis or peritoneal dialysis), one-quarter. Oral gastroparesis: CrCl under 60 mL/min, 5 mg four times daily (max 20 mg/day); ESRD, 5 mg twice daily (max 10 mg/day). Oral GERD: CrCl 60 mL/min or less, 5 mg four times daily or 10 mg three times daily (max 30 mg/day); ESRD, 5 mg four times daily or 10 mg twice daily (max 20 mg/day). Dialysis won't pull it out.
• Hepatic Impairment: Clearance falls about 50% in Child-Pugh C. Child-Pugh B or C, more than a single dose: half the injection dose. Oral gastroparesis: 5 mg four times daily (max 20 mg/day). Oral GERD: 5 mg four times daily or 10 mg three times daily (max 30 mg/day). Child-Pugh A needs no adjustment. Watch for fluid retention.
• Obesity / Dosing Weight: Adult antiemetic doses are fixed. They do not change with weight. The EU daily cap of 0.5 mg/kg is lower than 30 mg in adults under 60 kg. Pediatric doses use body weight, and they stop at the 10 mg adult dose.
• CYP2D6 Poor Metabolizers: Elimination is slower, and dystonia is more likely. US labeling: avoid the injection, or monitor closely if it is unavoidable. Oral gastroparesis: 5 mg four times daily (max 20 mg/day). Oral GERD: 5 mg four times daily or 10 mg three times daily (max 30 mg/day).
• NADH-Cytochrome b5 Reductase or G6PD Deficiency: Methemoglobinemia risk is higher. In G6PD deficiency, methylene blue is not recommended.

• Scope: Paramedic, RN and critical-care transport, where protocols include it. It varies by state and agency protocol.
• Storage & Stability: 20–25°C (68–77°F). Keep vials in the carton, since the drug is light sensitive. Single-dose vials have no preservative, so discard the unused portion. Discard discolored solution. Limit heat exposure in vehicles.
• Carried Concentration: 5 mg/mL. The usual adult dose, 10 mg, is one 2 mL vial. The injection is labeled for IV or IM use only.
• Infusions in Transport: A 10 mg dose in 50 mL saline over 15 min suits a stable patient. Run it on a pump or a controlled drip, and stay with the patient for the first minutes.
• Patient Safety in a Moving Vehicle: Akathisia can look like agitation or anxiety. It can make a patient try to get off the stretcher. Recognize it early. Stop or slow the infusion. Treat per protocol if distressing.
• Handoff Essentials: time, dose and route (push or infusion), response, any akathisia or dystonia and the rescue drug given, other dopamine antagonists given in the past 24–48 hr, and neuromuscular blocker plans (succinylcholine interaction).

Mechanism of Action

• Dopamine D2 blockade in the medullary chemoreceptor trigger zone → antiemetic effect.
• Sensitizes upper-GI smooth muscle to acetylcholine → stronger antral contractions, relaxed pylorus and duodenal bulb, faster gastric emptying and small-bowel transit, higher lower-esophageal-sphincter tone; blocked by anticholinergics; little effect on the colon.
• D2 blockade in the basal ganglia → akathisia, dystonia, parkinsonism and TD; pituitary D2 blockade → prolactin rise.
• Transient aldosterone rise → fluid retention; catecholamine release → hypertension.

Pharmacokinetics

• Half-life: 5–6 hr with normal renal function; about 10–15 hr in severe renal impairment.
• Bioavailability: oral about 80% (variable first-pass metabolism); IM 60–100% of IV.
• Metabolism: hepatic; CYP2D6 substrate (slower clearance in poor metabolizers and with strong CYP2D6 inhibitors); main metabolite is a sulfate conjugate.
• Elimination: about 85% of an oral dose in urine within 72 hr, about half as free or conjugated drug; not removed by dialysis.
• Distribution: volume of distribution about 3.5 L/kg; about 30% protein bound; crosses the blood–brain barrier and placenta and enters breast milk.

Generic Name

Metoclopramide hydrochloride. US doses and strengths are metoclopramide base; UK/EU labeling states strengths as anhydrous metoclopramide hydrochloride (10 mg of the hydrochloride is about 8.9 mg base)

Brand Names

Reglan (tablets); Gimoti (nasal spray); generic injection, tablets, ODT and oral solution

Pharmacologic Class

Dopamine D2 receptor antagonist (substituted benzamide)

Therapeutic Class

Antiemetic; upper-GI prokinetic

Controlled Substance

Not controlled