Included as part of the PRECAUTIONS section.
Tardive Dyskinesia (see Boxed Warnings)
Treatment with metoclopramide can cause tardive dyskinesia (TD), a potentially irreversible and disfiguring disorder characterized by involuntary movements of the face, tongue, or extremities. The risk of developing tardive dyskinesia increases with the duration of treatment and the total cumulative dose. An analysis of utilization patterns showed that about 20% of patients who used metoclopramide took it for longer than 12 weeks. Treatment with metoclopramide for longer than the recommended 12 weeks should be avoided in all but rare cases where therapeutic benefit is thought to outweigh the risk of developing TD.
Although the risk of developing TD in the general population may be increased among the elderly, women, and diabetics, it is not possible to predict which patients will develop metoclopramide-induced TD. Both the risk of developing TD and the likelihood that TD will become irreversible increase with duration of treatment and total cumulative dose.
Metoclopramide should be discontinued in patients who develop signs or symptoms of TD. There is no known effective treatment for established cases of TD, although in some patients, TD may remit, partially or completely, within several weeks to months after metoclopramide is withdrawn.
Metoclopramide itself may suppress, or partially suppress, the signs of TD, thereby masking the underlying disease process. The effect of this symptomatic suppression upon the long-term course of TD is unknown. Therefore, metoclopramide should not be used for the symptomatic control of TD.
Acute Dystonic Reactions, Drug-induced Parkinsonism, and Other Extrapyramidal
Extrapyramidal symptoms, manifested primarily as acute dystonic reactions, occur in approximately 1 in 500 patients treated with the usual adult dosages of 30 to 40 mg/day of metoclopramide. These usually are seen during the first 24 to 48 hours of treatment with metoclopramide, occur more frequently in pediatric patients and adult patients less than 30 years of age and are even more frequent at higher doses. These symptoms may include involuntary movements of limbs and facial grimacing, torticollis, oculogyric crisis, rhythmic protrusion of tongue, bulbar type of speech, trismus, or dystonic reactions resembling tetanus. Rarely, dystonic reactions may present as stridor and dyspnea, possibly due to laryngospasm. If these symptoms should occur, inject 50 mg diphenhydramine hydrochloride intramuscularly. Benztropine mesylate, 1 to 2 mg intramuscularly, may also be used to reverse these reactions.
Parkinsonian-like symptoms have occurred, more commonly within the first 6 months after beginning treatment with metoclopramide, but occasionally after longer periods. These symptoms generally subside within 2 to 3 months following discontinuance of metoclopramide. Patients with preexisting Parkinson's disease should be given metoclopramide cautiously, if at all, since such patients may experience exacerbation of parkinsonian symptoms when taking metoclopramide.
Neuroleptic Malignant Syndrome (NMS)
There have been rare reports of an uncommon but potentially fatal symptom complex sometimes referred to as Neuroleptic Malignant Syndrome (NMS) associated with metoclopramide. Clinical manifestations of NMS include hyperthermia, muscle rigidity, altered consciousness, and evidence of autonomic instability (irregular pulse or blood pressure, tachycardia, diaphoresis and cardiac arrhythmias).
The diagnostic evaluation of patients with this syndrome is complicated. In arriving at a diagnosis, it is important to identify cases where the clinical presentation includes both serious medical illness (e.g., pneumonia, systemic infection, etc.) and untreated or inadequately treated extrapyramidal signs and symptoms (EPS). Other important considerations in the differential diagnosis include central anticholinergic toxicity, heat stroke, malignant hyperthermia, drug fever and primary central nervous system (CNS) pathology.
The management of NMS should include 1) immediate discontinuation of metoclopramide
and other drugs not essential to concurrent therapy, 2) intensive symptomatic
treatment and medical monitoring, and 3) treatment of any concomitant serious
medical problems for which specific treatments are available. Bromocriptine
and dantrolene sodium have been used in treatment of NMS, but their effectiveness
have not been established [see ADVERSE REACTIONS].
Mental depression has occurred in patients with and without prior history of depression. Symptoms have ranged from mild to severe and have included suicidal ideation and suicide. Metoclopramide should be given to patients with a prior history of depression only if the expected benefits outweigh the potential risks.
In one study in hypertensive patients, intravenously administered metoclopramide
was shown to release catecholamines; hence, caution should be exercised when
metoclopramide is used in patients with hypertension. There are also clinical
reports of hypertensive crises in some patients with undiagnosed pheochromocytoma,
thus any rapid rise in blood pressure associated with REGLAN ODT™ use
should result in immediate cessation of metoclopramide use in those patients
Congestive Heart Failure and Ventricular Arrhythmia
Because metoclopramide produces a transient increase in plasma aldosterone, certain patients, especially those with cirrhosis or congestive heart failure, may be at risk of developing fluid retention and volume overload. If these side effects occur at any time during metoclopramide therapy, the drug should be discontinued.
Withdrawal from Metoclopramide
Adverse reactions, especially those involving the nervous system, may occur after stopping the use of REGLAN ODT™ (metoclopramide orally disintegrating tablets) . A small number of patients may experience a withdrawal period after stopping REGLAN ODT™ (metoclopramide orally disintegrating tablets) that could include dizziness, nervousness, and/or headaches.
Patient Counseling Information
[See Medication Guide]
Instruct patients to take REGLAN ODT™ (metoclopramide orally disintegrating tablets) at least 30 minutes before eating and at bedtime.
Instruct patients not to remove REGLAN ODT™ (metoclopramide orally disintegrating tablets) orally disintegrating tablets from the packaging until just prior to dosing. With dry hands, the patient should remove the tablet from the package and immediately place the tablet on the tongue to disintegrate and be swallowed with the saliva. The tablet typically disintegrates in about one and one-half minutes. Administration with liquid is not necessary.
Inform patients or their caregivers of serious potential issues associated with metoclopramide use such as tardive dyskinesia, extrapyramidal symptoms, and neuroleptic malignant syndrome. Advise patients to inform their physician if symptoms associated with these disorders occur during or after treatment with REGLAN ODT™ .
Inform patients that metoclopramide may cause drowsiness, dizziness, or otherwise impair the mental and/or physical abilities required for the performance of hazardous tasks such as operating machinery or driving a motor vehicle. Sedation may be more pronounced in the elderly. The ambulatory patient should be cautioned accordingly.
Inform patients that the most common adverse reactions in patients treated with REGLAN ODT™ or other metoclopramide-containing products are headache, nausea, vomiting, tiredness, sleepiness, dizziness, and restlessness.
Phenylketonuric patients should be informed that REGLAN ODT™ (metoclopramide orally disintegrating tablets) contains phenylalanine 4.2 mg per 5 mg orally disintegrating tablet and 8.3 mg per 10 mg orally disintegrating tablet.
For additional information, patients should be instructed to see the Medication
Guide for REGLAN ODT™ (metoclopramide orally disintegrating tablets) .
Carcinogenesls, Mutagenesis, and Impairment of Fertility
A 77-week study was conducted in rats with oral doses of metoclopramide up
to 40 mg/kg/day (about 5 times the maximum recommended human dose on surface
area basis). Metoclopramide elevates prolactin levels and the elevation persists
during chronic administration. Tissue culture experiments indicate that approximately
one-third of human breast cancers are prolactin-dependent in vitro, a
factor of potential importance if the prescription of metoclopramide is contemplated
in a patient with previously detected breast cancer. Although disturbances such
as galactorrhea, amenorrhea, gynecomastia, and impotence have been reported
with prolactin-elevating drugs, the clinical significance of elevated serum
prolactin levels is unknown for most patients. An increase in mammary neoplasms
has been found in rodents after chronic administration of prolactin-stimulating
neuroleptic drugs and metoclopramide. Neither clinical studies nor epidemiologic
studies conducted to date, however, have shown an association between chronic
administration of these drugs and mammary tumorigenesis; the available evidence
is too limited to be conclusive at this time.
In a rat model for assessing the tumor promotion potential, a two-week oral treatment with metoclopramide at a dose of 260 mg/kg/day (about 35 times the maximum recommended human dose on surface area basis) enhanced the tumorigenic effect of N-nitrosodiethylamine.
Metoclopramide was positive in the Chinese hamster lung cell/HGPRT
forward mutation assay for mutagenic effects and the in vitro human lymphocyte chromosome aberration assay for clastogenic effects. It was negative in the
in vitro Ames mutation assay, the in vitro unscheduled DNA synthesis
(UDS) assay with rat and human hepatocytes and the in vivo rat micronucleus
Metoclopramide at intramuscular doses up to 20 mg/kg/day in male and female rats (about 3 times the maximum recommended human dose on surface area basis) was found to have no effect on fertility and reproductive performance.
Use In Specific Populations
Teratogenic Effects: Pregnancy Category B. Teratology studies have been
performed in rats at oral doses up to 45 mg/kg/day (about 6 times the maximum
recommended human dose on surface area basis), and in rabbits at oral doses
up to 45 mg/kg/day (about 12 times the maximum recommended human dose on surface
area basis) and have revealed no evidence of impaired fertility or harm to the
fetus due to metoclopramide. There are, however, no adequate and well-controlled
studies in pregnant women. Because animal reproduction studies are not always
predictive of human response, this drug should be used during pregnancy only
if clearly needed.
Labor and Delivery
The use of metoclopramide in labor and delivery has not been studied.
Metoclopramide is excreted in human milk. Caution should be exercised when metoclopramide is administered to a nursing mother. Because of the potential for serious adverse reactions in nursing infants from metoclopramide and because of the potential for tumorigenicity and tumor promoting potential shown for metoclopramide in rats, a decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother.
Safety and effectiveness in pediatric patients have not been established [see
Care should be exercised in administering metoclopramide to neonates since
prolonged clearance may produce excessive serum concentrations [see CLINICAL
PHARMACOLOGY]. In addition, neonates have reduced levels of NADH-cytochrome
b5 reductase which, in combination with the aforementioned pharmacokinetic factors,
make neonates more susceptible to methemoglobinemia, a possible side effect
of metoclopramide use in neonates [see OVERDOSAGE].
The safety profile of metoclopramide in adults cannot be extrapolated to pediatric
patients. Dystonias and other extrapyramidal reactions associated with metoclopramide
are more common in the pediatric population than in adults, [seeWARNINGS AND PRECAUTIONS and ADVERSE REACTIONS]
Clinical studies of metoclopramide did not include sufficient numbers of subjects aged 65 and over to determine whether elderly subjects respond differently from younger subjects.
The risk of developing parkinsonian-like side effects increases with ascending
dose. Geriatric patients should receive the lowest dose of REGLAN ODT™ (metoclopramide orally disintegrating tablets)
that is effective. If parkinsonian-like symptoms develop in a geriatric patient
receiving REGLAN ODT™ (metoclopramide orally disintegrating tablets) , REGLAN ODT™ (metoclopramide orally disintegrating tablets) should be discontinued before
initiating any specific anti-parkinsonian agents [see WARNINGS AND PRECAUTIONS
and DOSAGE AND ADMINISTRATION].
The elderly may be at greater risk for tardive dyskinesia [see WARNINGS AND PRECAUTIONS].
Sedation has been reported in metoclopramide users. Sedation may cause confusion
and manifest as over-sedation in the elderly [see CLINICAL PHARMACOLOGY,
ADVERSE REACTIONS, and PATIENT INFORMATION].
Metoclopramide is known to be substantially excreted by the kidney, and the
risk of toxic reactions to this drug may be greater in patients with impaired
renal function [see DOSAGE AND ADMINISTRATION].
For these reasons, dose selection for an elderly patient should be cautious,
usually starting at the low end of the dosing range, reflecting the greater
frequency of decreased renal function, concomitant disease, or other drug therapy
in the elderly [see DOSAGE AND ADMINISTRATION].
Metoclopramide has been safely used in patients with advanced liver disease
whose renal function was normal.
Renally impaired patients whose creatinine clearance is below 40 mL/min may
be more sensitive to the therapeutic dose or the adverse effects of metoclopramide.
Therefore, these patients should start therapy at a lower dose (approximately
half the recommended dosage) and the dose should be titrated according to their
overall clinical response and/or adverse event profile. Dialysis is not likely
to be an effective method of drug removal in overdose situations. (See DOSAGE
Other Special Populations
Patients with NADH-cytochrome b5 reductase deficiency are at an increased risk
of developing methemoglobinemia and/or sulfhemoglobinemia when metoclopramide
is administered. In patients with G6PD deficiency who experience metoclopramide-induced
methemoglobinemia, methylene blue treatment is not recommended [see OVERDOSAGE].