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Ouyang X, Qu R, Hu B, Wang Y, Yao F, Lv B, Sun C, Deng Y, Chen C. Is metoclopramide beneficial for the postpyloric placement of nasoenteric tubes? A systematic review and meta-analysis of randomized controlled trials. Nutr Clin Pract 2021; 37:316-327. [PMID: 34155678 PMCID: PMC9292665 DOI: 10.1002/ncp.10725] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Background Metoclopramide is frequently prescribed as an adjuvant for the postpyloric placement of nasoenteric tubes (NETs). However, a recent meta‐analysis showed that metoclopramide was not beneficial in adults. Thus, this study aimed to reevaluate the effect of metoclopramide on the postpyloric placement of NETs. Methods A systematic search of PubMed, Embase, the Cochrane Library, Web of Science, Chinese National Knowledge Infrastructure (CNKI), and Wanfang data was conducted up to August 2020 for randomized controlled trials (RCTs) comparing metoclopramide with placebo or no intervention. Trial sequential analysis (TSA) was used for the primary outcomes (the success rate of the postpyloric placement of NETs). Results Seven eligible RCTs that included 520 participants were identified. The results of the pooled effect sizes showed that metoclopramide significantly facilitated the postpyloric placement of NETs (relative risk [RR], 1.48; 95% CI, 1.11–1.97; P = .007; I2 = 37%). However, the risk‐of‐bias assessment and the TSA results indicated that the qualities of the RCTs and the sample sizes were insufficient to confirm the efficacy of metoclopramide. Further subgroup analysis revealed that successful postpyloric placement was more pronounced in studies in which spiral NETs were employed (RR, 1.85; 95% CI, 1.41–2.43; P < .001; I2 = 0%). Additionally, overall adverse events were minimal. Conclusions The evidence accumulated so far was not strong enough to demonstrate metoclopramide's beneficial effects on the postpyloric placement of NETs. Further high‐quality, large‐sample RCTs are required to elucidate the effects of metoclopramide.
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Affiliation(s)
- Xin Ouyang
- Department of Intensive Care Unit of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Rong Qu
- Department of Critical Care Medicine, Huizhou Municipal Central Hospital, Huizhou, Guangdong, China
| | - Bei Hu
- Department of Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Yifan Wang
- Department of Intensive Care Unit of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Fen Yao
- Department of Intensive Care Unit of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Bo Lv
- Department of Intensive Care Unit of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Cheng Sun
- Department of Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Yiyu Deng
- Department of Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China.,The Second School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong, China
| | - Chunbo Chen
- Department of Intensive Care Unit of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China.,Department of Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China.,The Second School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong, China
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2
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Al-Saffar A, Lennernäs H, Hellström PM. Gastroparesis, metoclopramide, and tardive dyskinesia: Risk revisited. Neurogastroenterol Motil 2019; 31:e13617. [PMID: 31050085 DOI: 10.1111/nmo.13617] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 04/13/2019] [Accepted: 04/17/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND Metoclopramide is primarily a dopamine receptor antagonist, with 5HT3 receptor antagonist and 5HT4 receptor agonist activity, and used as an antiemetic and gastroprokinetic since almost 50 years. Regulatory authorities issued restrictions and recommendations regarding long-term use of the drug at oral doses exceeding 10 mg 3-4 times daily because of the risk for development of tardive dyskinesia. The aim of our study was to review mechanism(s) of action and pharmacokinetic-pharmacodynamic properties of metoclopramide, as well as the risk of metoclopramide-induced tardive dyskinesia, factors that may change drug exposure in humans, and to summarize the clinical context for appropriate use of the drug. METHODS A PubMed, Google Scholar, and Cross Reference search was done using the key words and combined searches: drug-drug interaction, gastroparesis, metoclopramide, natural history, pharmacokinetics, pharmacodynamics, drug-drug interaction, outcome, risk factors, tardive dyskinesia. KEY RESULTS Data show that the risk of tardive dyskinesia from metoclopramide is low, in the range of 0.1% per 1000 patient years. This is far below a previously estimated 1%-10% risk suggested in treatment guidelines by regulatory authorities. High-risk groups are elderly females, diabetics, patients with liver or kidney failure, and patients with concomitant antipsychotic drug therapy, which reduces the threshold for neurological complications. CONCLUSIONS & INFERENCES The risk of tardive dyskinesia due to metoclopramide is far below approximated numbers in treatment guidelines. This risk and the influence of known risk factors should be considered when starting a course of metoclopramide for treatment of gastroparesis.
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Affiliation(s)
- Ahmad Al-Saffar
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Hans Lennernäs
- Department of Pharmacy, Uppsala University, Uppsala, Sweden
| | - Per M Hellström
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
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Kaukab I, Hussain Shah SN, Murtaza G. Single Dose Pharmacokinetics of Metoclopramide Oral Tablets Utilizing HPLC-UV Method. CURR PHARM ANAL 2019. [DOI: 10.2174/1573412914666180425123202] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background:
Metoclopramide is a potent dopaminergic antagonist utilized for treating gastrointestinal
disorders. The aim of this study was to examine the pharmacokinetics of oral formulation
of metoclopramide in the Pakistani volunteers.
Methods:
This open label, single dose, pharmacokinetic study was executed in non-smoking, 12 Pakistani
healthy males, treated with a single 20 mg oral tablet dose of metoclopramide on test day. Maximum
plasma concentration (Cmax), time to achieve Cmax (Tmax), and area under curve (AUC0-t) of metoclopramide
were determined analyzing the serial blood samples using a validated HPLC-UV method.
Results:
The determined values of Cmax, Tmax, and AUC0-t of metoclopramide were 34.51 ± 4.91 ng/ml,
1.56 ± 0.18 and 273.88 ± 114.49 ng.h/ml, respectively.
Conclusion:
The results reveal that the findings of Pakistani individuals are slightly different when
compared with the published data of other ethnic origins.
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Affiliation(s)
- Iram Kaukab
- Department of Pharmaceutics, Faculty of Pharmacy, Bahauddin Zakariya University, Multan, Pakistan
| | - Syed Nisar Hussain Shah
- Department of Pharmaceutics, Faculty of Pharmacy, Bahauddin Zakariya University, Multan, Pakistan
| | - Ghulam Murtaza
- Department of Pharmacy, COMSATS Institute of Information Technology, Abbottabad 22060, Pakistan
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Bernardo-Escudero R, Alonso-Campero R, de Jesús Francisco-Doce MT, Cortés-Fuentes M, Villa-Vargas M, Angeles-Uribe J. Comparison of the pharmacokinetics of a new 15-mg modified-release tablet formulation of metoclopramide versus a 10-mg immediate-release tablet: a single- and multiple-dose, randomized, open-label, parallel-group study in healthy Mexican male volunteers. Clin Ther 2011; 33:630-43. [PMID: 21665047 DOI: 10.1016/j.clinthera.2011.04.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND Metoclopramide is a prokinetic and antiemetic agent. OBJECTIVE The goal of this study was to assess the pharmacokinetics of a new, modified-release metoclopramide tablet and compare it with an immediate-release tablet to obtain marketing approval from the Mexican regulatory agency. METHODS This was a single-center, randomized, open-label, parallel-group, single- and multiple-dose, pharmacokinetic study. Investigational products were administered to healthy Mexican male volunteers for 3 consecutive days: one 15-mg modified-release tablet every 12 hours or one 10-mg immediate-release tablet every 8 hours. Multiple blood samples were collected after the first and last doses of metoclopramide over a 24-hour period. Plasma metoclopramide concentrations were determined by using a validated HPLC method. Safety and tolerability were assessed by measurement of vital signs, clinical evaluations, and spontaneous reports from study subjects. RESULTS All 26 subjects were included in the analyses (mean [SD] age: 25 [6] years [range, 18-40 years]; body mass index, 23.44 [2.31] kg/m(2) [range, 18.26-27.49 kg/m2]). Peak plasma concentrations were lower (C(max), 33.13 [7.25] vs 46.04 [17.27] ng/mL after the first dose [P < 0.05]; C(max,ss), 48.60 [8.52] vs 75.23 [21.27] ng/mL after the last dose [P < 0.05]) and occurred later (P < 0.05) with the modified-release formulation. In terms of average plasma concentrations (C(avgτ), 20.98 [3.94] vs 23.38 [7.35] ng/mL after the first dose; C(avg,ss), 22.20 [5.64] vs 23.02 [7.77] ng/mL after the last dose), differences did not reach the level of statistical significance (P > 0.05). Four adverse events were reported in the test group (abdominal distention [n = 2], epigastric pain [n = 1], and somnolence [n = 1]), and 3 were reported in the reference group (epigastric pain [n = 1], diarrhea [n = 1], and hiccups [n = 1]). CONCLUSIONS This study in a sample of selected healthy Mexican male volunteers suggests that the metoclopramide15-mg modified-release tablets have features compatible with the slow-release formulation (lower C(max) and longer T(max)) compared with immediate-release tablets.
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Affiliation(s)
- Roberto Bernardo-Escudero
- Asociación Mexicana para la Investigación Clínica, A.C. (Mexican Association for Clinical Research), Pachuca, Hidalgo, Mexico.
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Stosik A, Junginger H, Kopp S, Midha K, Shah V, Stavchansky S, Dressman J, Barends D. Biowaiver Monographs for Immediate Release Solid Oral Dosage forms: Metoclopramide Hydrochloride. J Pharm Sci 2008; 97:3700-8. [DOI: 10.1002/jps.21276] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Shields BJ, Mackichan JJ. High-Performance Liquid Chromatographic Method for the Determination of Metoclopramide in Plasma. ACTA ACUST UNITED AC 2006. [DOI: 10.1080/01483919008049060] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Lindenberg M, Kopp S, Dressman JB. Classification of orally administered drugs on the World Health Organization Model list of Essential Medicines according to the biopharmaceutics classification system. Eur J Pharm Biopharm 2005; 58:265-78. [PMID: 15296954 DOI: 10.1016/j.ejpb.2004.03.001] [Citation(s) in RCA: 493] [Impact Index Per Article: 25.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2004] [Accepted: 02/05/2004] [Indexed: 01/01/2023]
Abstract
Since its inception in 1995, the biopharmaceutical classification system (BCS) has become an increasingly important tool for regulation of drug products world-wide. Until now, application of the BCS has been partially hindered by the lack of a freely available and accurate database summarising solubility and permeability characteristics of drug substances. In this report, orally administered drugs on the Model list of Essential Medicines of the World Health Organization (WHO) are assigned BCS classifications on the basis of data available in the public domain. Of the 130 orally administered drugs on the WHO list, 61 could be classified with certainty. Twenty-one (84%) of these belong to class I (highly soluble, highly permeable), 10 (17%) to class II (poorly soluble, highly permeable), 24 (39%) to class III (highly soluble, poorly permeable) and 6 (10%) to class IV (poorly soluble, poorly permeable). A further 28 drugs could be provisionally assigned, while for 41 drugs insufficient or conflicting data precluded assignment to a specific BCS class. A total of 32 class I drugs (either certain or provisional classification) were identified. These drugs can be further considered for biowaiver status (drug product approval based on dissolution tests rather than bioequivalence studies in humans).
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Affiliation(s)
- Marc Lindenberg
- Department of Pharmaceutical Technology, Johann Wolfgang Goethe-University, Frankfurt am Main, Germany
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Albani F, Tamè MR, De Palma R, Bernardi M. Kinetics of intravenous metoclopramide in patients with hepatic cirrhosis. Eur J Clin Pharmacol 1991; 40:423-5. [PMID: 2050180 DOI: 10.1007/bf00265857] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The pharmacokinetics of metoclopramide has been studied after acute IV administration to 12 patients with hepatic cirrhosis (6 with and 6 without ascites) and 6 control subjects. The elimination half-life was significantly longer in patients (11.4 h and 9.9 h in those with and without ascites, respectively, vs 6.4 h in controls). Total plasma clearance was significantly lower in patients (0.29 and 0.36 l.kg-1.h-1 vs 0.52 l.kg-1.h-1 in controls). The differences between patients with and without ascites did not reach statistical significance. Reduction of functional hepatic blood flow in cirrhotic patients is the probable cause of the observed alteration in metoclopramide kinetics.
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Affiliation(s)
- F Albani
- Laboratory of Neuropharmacology, Institute of Clinical Neurology, Bologna, Italy
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Magueur E, Hagege H, Attali P, Singlas E, Etienne JP, Taburet AM. Pharmacokinetics of metoclopramide in patients with liver cirrhosis. Br J Clin Pharmacol 1991; 31:185-7. [PMID: 2049236 PMCID: PMC1368389 DOI: 10.1111/j.1365-2125.1991.tb05511.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
The pharmacokinetics of metoclopramide were investigated after intravenous and oral administration in eight patients with severe alcoholic cirrhosis and in eight healthy volunteers. As a consequence of a 50% lower clearance (0.16 +/- 0.07 vs 0.34 +/- 0.09 l h-1 kg-1, plasma drug concentrations and the half-life of metoclopramide were greater in patients following both routes of drug administration. Volume of distribution (3.1 +/- 0.8 vs 3.4 +/- 1.2 l kg-1) and absolute bioavailability (79 +/- 19 vs 84 +/- 15%) were similar in the two groups. The adverse effects of metoclopramide observed in patients with marked hepatic impairment are likely to result from increased accumulation of the drug as a result of impaired clearance. Consequently a reduction in dose of 50% is recommended in patients with severe liver cirrhosis.
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Affiliation(s)
- E Magueur
- Department of Clinical Pharmacy, Bicêtre Hospital, Le Kremlin Bicêtre, France
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Wright MR, Axelson JE, Rurak DW, McErlane B, McMorland GH, Ongley RC, Tam YK, Price JD. Effect of haemodialysis on metoclopramide kinetics in patients with severe renal failure. Br J Clin Pharmacol 1988; 26:474-7. [PMID: 3190998 PMCID: PMC1386571 DOI: 10.1111/j.1365-2125.1988.tb03408.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
The kinetics of metoclopramide and the effects of haemodialysis on metoclopramide kinetics were examined in eight uraemic subjects 1 h and 24 h prior to the onset of dialysis. In spite of the relatively minor contribution of renal clearance to total body clearance in normals, metoclopramide kinetics were substantially altered in uraemia. The total body clearance was decreased by 2-4 fold, terminal elimination half-life proportionately increased, while the volume of distribution appeared to be unaffected compared with that previously demonstrated in normal healthy subjects. Haemodialysis does not appear to be effective in removing metoclopramide from the body and metoclopramide clearance subsequent to dialysis is unaltered. The kinetic parameters in the uraemic subjects are not significantly different between drug administrations 1 or 24 h prior to the time of onset of haemodialysis. Following kidney transplantation, in one subject, there appeared to be a rapid return to apparently normal kinetics from the uraemic state.
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Affiliation(s)
- M R Wright
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada
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