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Drug Insight: from disturbed motility to disordered movement—a review of the clinical benefits and medicolegal risks of metoclopramide

Nature Clinical Practice Gastroenterology & Hepatology volume 3, pages 138–148 (2006)Cite this article

Abstract

Metoclopramide, the only drug approved by the FDA for treatment of diabetic gastroparesis, but used off-label for a variety of other gastrointestinal indications, has many potentially troublesome adverse neurologic effects, particularly movement disorders. In this article, we comprehensively review the indications and side effects of metoclopramide, and describe some common pitfalls and strategies to minimize the medicolegal risks to the prescribing physician. Metoclopramide accounts for nearly a third of all drug-induced movement disorders, a common reason for a malpractice suit. The entire spectrum of drug-induced movement disorders, ranging from subtle to life-threatening, can ensue from its use; akathisia and dystonia are generally seen early in the course of metoclopramide-induced movement disorders, whereas tardive dyskinesia and parkinsonism seem to be more prevalent in chronic users. Female sex, age and diabetes are the major risk factors for metoclopramide-induced movement disorders. It is therefore incumbent on gastroenterologists and other prescribing physicians to become familiar with the adverse neurologic effects associated with the use of metoclopramide, and to take appropriate preventive and defensive measures.

Key Points

  • Patients most at risk of developing metoclopramide-induced movement disorders are women, the elderly, and diabetics

  • A method for screening for neurologic complications should be developed at baseline and follow-up visits

  • Patient-oriented literature on side effects should be provided and informed consent should be obtained before prescribing metoclopramide

  • The evidence for efficacy in a given patient should be periodically reviewed and complete discontinuation or drug 'holidays' considered

  • Doses of metoclopramide >10 mg 3–4 times daily should be avoided unless absolutely necessary

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Figure 1: Prescriptions of metoclopramide by US community pharmacies: the influence of cisapride approval and withdrawal.
Figure 2: Use of metoclopramide by patient age in US physician practices from 1992–2002.
Figure 3: Schematic representation of effect of metoclopramide on the dopaminergic pathways in the upper gastrointestinal tract.

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Authors and Affiliations

  1. Professor of Anatomy & Neurosciences and Biomedical Engineering and the Chief of the Division of Gastroenterology and Hepatology,

    P Jay Pasricha, Nonko Pehlivanov & Aravind Sugumar

  2. Assistant Professor and Associate Director of the Gastrointestinal Motility Laboratory,

    P Jay Pasricha, Nonko Pehlivanov & Aravind Sugumar

  3. second-year internal medical resident at the University of Texas Medical Branch, Galveston, TX

    P Jay Pasricha, Nonko Pehlivanov & Aravind Sugumar

  4. Department of Neurology, Professor of Neurology and the Director of the Parkinson's Disease Center and Movement Disorders Clinic, Baylor College of Medicine, Houston, TX, USA

    Joseph Jankovic

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Correspondence to P Jay Pasricha.

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Pasricha, P., Pehlivanov, N., Sugumar, A. et al. Drug Insight: from disturbed motility to disordered movement—a review of the clinical benefits and medicolegal risks of metoclopramide. Nat Rev Gastroenterol Hepatol 3, 138–148 (2006). https://doi.org/10.1038/ncpgasthep0442

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