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Bor S, Kalkan İH, Savarino E, Rao S, Tack J, Pasricha J, Cangemi D, Schol J, Karunaratne T, Ghisa M, Ahuja NK, Lacy B. Prokinetics-safety and efficacy: The European Society of Neurogastroenterology and Motility/The American Neurogastroenterology and Motility Society expert review. Neurogastroenterol Motil 2024; 36:e14774. [PMID: 38462678 DOI: 10.1111/nmo.14774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 02/02/2024] [Accepted: 02/13/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND Prokinetics are a class of pharmacological drugs designed to improve gastrointestinal (GI) motility, either regionally or across the whole gut. Each drug has its merits and drawbacks, and based on current evidence as high-quality studies are limited, we have no clear recommendation on one class or other. However, there remains a large unmet need for both regionally selective and/or globally acting prokinetic drugs that work primarily intraluminally and are safe and without systemic side effects. PURPOSE Here, we describe the strengths and weaknesses of six classes of prokinetic drugs, including their pharmacokinetic properties, efficacy, safety and tolerability and potential indications.
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Affiliation(s)
- Serhat Bor
- Division of Gastroenterology, School of Medicine & Ege Reflux Study Group, Ege University, Izmir, Turkey
| | - İsmail H Kalkan
- Department of Gastroenterology, School of Medicine, TOBB University of Economics and Technology, Ankara, Turkey
| | - Edoardo Savarino
- Gastroenterology Unit, Azienda Ospedale Università di Padova (AOUP), Padua, Italy
| | - Satish Rao
- Division of Gastroenterology and Hepatology, Digestive Health Center, Augusta University, Augusta, Georgia, USA
| | - Jan Tack
- Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
| | - Jay Pasricha
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - David Cangemi
- Division of Gastroenterology & Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Jolien Schol
- Translational Research Center for Gastrointestinal Disorders, University of Leuven, Leuven, Belgium
| | - Tennekon Karunaratne
- Division of Gastroenterology/Hepatology, Medical College of Georgia, Augusta University, Augusta, Georgia, USA
| | - Matteo Ghisa
- Digestive Endoscopy Unit, Division of Gastroenterology, Padua University Hospital, Padua, Italy
| | - Nitin K Ahuja
- Division of Gastroenterology, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Brian Lacy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
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Cortel-LeBlanc MA, Orr SL, Dunn M, James D, Cortel-LeBlanc A. Managing and Preventing Migraine in the Emergency Department: A Review. Ann Emerg Med 2023; 82:732-751. [PMID: 37436346 DOI: 10.1016/j.annemergmed.2023.05.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 05/24/2023] [Accepted: 05/25/2023] [Indexed: 07/13/2023]
Abstract
Migraine is a leading cause of disability worldwide, and acute migraine attacks are a common reason for patients to seek care in the emergency department (ED). There have been recent advancements in the care of patients with migraine, specifically emerging evidence for nerve blocks and new pharmacological classes of medications like gepants and ditans. This article serves as a comprehensive review of migraine in the ED, including diagnosis and management of acute complications of migraine (eg, status migrainosus, migrainous infarct, persistent aura without infarction, and aura-triggered seizure) and use of evidence-based migraine-specific treatments in the ED. It highlights the role of migraine preventive medications and provides a framework for emergency physicians to prescribe them to eligible patients. Finally, it evaluates the evidence for nerve blocks in the treatment of migraine and introduces the possible role of gepants and ditans in the care of patients with migraine in the ED.
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Affiliation(s)
- Miguel A Cortel-LeBlanc
- Department of Emergency Medicine, Queensway Carleton Hospital, Ottawa, ON, Canada; Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada; Institut du Savoir Montfort, Ottawa, ON, Canada; 360 Concussion Care, Ottawa, ON, Canada.
| | - Serena L Orr
- Departments of Pediatrics, Community Health Sciences, and Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
| | - Maeghan Dunn
- Department of Emergency Medicine, Queensway Carleton Hospital, Ottawa, ON, Canada
| | - Daniel James
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada; Department of Emergency Medicine, The Ottawa Hospital, Ottawa, ON, Canada; Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, ON, Canada
| | - Achelle Cortel-LeBlanc
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada; Institut du Savoir Montfort, Ottawa, ON, Canada; 360 Concussion Care, Ottawa, ON, Canada; Division of Neurology, Department of Medicine, Queensway Carleton Hospital, Ottawa, ON, Canada
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3
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Gottlieb M, Carlson JN, Peksa GD. Prophylactic antiemetics for adults receiving intravenous opioids in the acute care setting. Cochrane Database Syst Rev 2022; 5:CD013860. [PMID: 35588093 PMCID: PMC9119423 DOI: 10.1002/14651858.cd013860.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Physicians often prescribe opioids for pain in the acute care setting. Nausea and vomiting are well-described adverse events, occurring in over one-third of patients. Prophylactic antiemetics may be one option to reduce opioid-associated nausea and vomiting. However, these medications also have their own adverse effects, so it is important to understand their efficacy and safety prior to routine use. This is a review of randomized controlled trials comparing prophylactic antiemetics versus placebo or standard care for preventing opioid-associated nausea and vomiting. OBJECTIVES To assess the effects of prophylactic antiemetics for nausea and vomiting in adults (aged 16 years or older) receiving intravenous opioids in the acute care setting. SEARCH METHODS We searched CENTRAL (the Cochrane Library), MEDLINE (OVID), Embase (OVID) from inception to January 2022, and Google Scholar (17 January 2022). We also searched the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) and screened reference lists. SELECTION CRITERIA We included randomized controlled trials of prophylactic antiemetics versus placebo or standard care in adults prior to receiving an intravenous opioid. DATA COLLECTION AND ANALYSIS Two review authors (MG, JNC) independently determined the eligibility of each study according to the inclusion criteria. Two review authors (MG, GDP) then independently extracted data, assessed risk of bias, and determined the certainty of evidence using GRADE. Our primary outcomes were the occurrence of nausea, vomiting, and adverse events. Secondary outcomes included nausea severity, number of vomiting episodes, and number of participants requiring antiemetic rescue therapy. We presented outcomes as risk ratios (RR) for dichotomous data (e.g. presence of vomiting, presence of nausea, number of participants requiring rescue medication, adverse events) and mean difference (MD) or standardized mean difference for continuous data (e.g. number of vomiting episodes, nausea severity) with 95% confidence intervals (CI). MAIN RESULTS We included three studies involving 527 participants (187 women and 340 men) with a mean age of 42 years. All studies used intravenous metoclopramide (10 mg) as the intervention and a placebo for the comparator. No studies assessed any other antiemetic or compared the intervention to standard care. Compared to placebo, metoclopramide did not reduce vomiting (RR 1.18, 95% CI 0.26 to 5.32; low-certainty evidence) or nausea (RR 0.55; 95% CI 0.15 to 2.03; low-certainty evidence) and there was no difference in adverse events (RR 2.34, 95% CI 0.47 to 11.61; low-certainty evidence). No data were available regarding the number of vomiting episodes. Metoclopramide did reduce the severity of nausea compared with placebo (MD -0.49, 95% CI -0.75 to -0.23; low-certainty evidence) but did not reduce the need for rescue medication (RR 1.86, 95% CI 0.17 to 20.16; low-certainty evidence). Two studies were at unclear risk of bias for random sequence generation, one for blinding of outcome assessors, one for incomplete outcome data, and two for selective reporting. The studies were at low risk of bias for all remaining components. AUTHORS' CONCLUSIONS There was no evidence that prophylactic metoclopramide affected the risk of vomiting, nausea, or the need for rescue medication when provided prior to intravenous opioids in the acute care setting. There was a clinically insignificant difference in nausea severity when comparing prophylactic metoclopramide with placebo. Overall, the evidence was of low certainty. Future research could better delineate the effects of prophylactic antiemetics on specific populations, and new studies are needed to evaluate the use of other prophylactic antiemetic agents, for which there were no data.
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Affiliation(s)
- Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Jestin N Carlson
- Emergency Department, Allegheny Health Network, Erie, Pennsylvania, USA
| | - Gary D Peksa
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA
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4
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Gottlieb M, Carlson JN, Peksa GD. Prophylactic antiemetics for adults receiving intravenous opioids in the acute care setting. Hippokratia 2021. [DOI: 10.1002/14651858.cd013860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Michael Gottlieb
- Department of Emergency Medicine; Rush University Medical Center; Chicago IL USA
| | - Jestin N Carlson
- Emergency Department; Allegheny Health Network; Erie Pennsylvania USA
| | - Gary D Peksa
- Department of Emergency Medicine; Rush University Medical Center; Chicago IL USA
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Chapman MJ, Jones KL, Almansa C, Barnes CN, Nguyen D, Deane AM. Blinded, Double-Dummy, Parallel-Group, Phase 2a Randomized Clinical Trial to Evaluate the Efficacy and Safety of a Highly Selective 5-Hydroxytryptamine Type 4 Receptor Agonist in Critically Ill Patients With Enteral Feeding Intolerance. JPEN J Parenter Enteral Nutr 2020; 45:115-124. [PMID: 31990087 PMCID: PMC7891369 DOI: 10.1002/jpen.1732] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 09/23/2019] [Accepted: 10/05/2019] [Indexed: 12/22/2022]
Abstract
Background Delayed gastric emptying is the leading cause of enteral feeding intolerance (EFI) in critical illness. This phase 2a study compared TAK‐954, a selective agonist of 5‐hydroxytryptamine type 4 receptors, with metoclopramide in critically ill patients with EFI (NCT01953081). Methods A blinded, double‐dummy trial was conducted in mechanically ventilated patients with EFI (>200 mL gastric residual volume within 24 hours before randomization). Patients were randomized to receive either 0.5 mg intravenous TAK‐954 over 1 hour then 0.9% saline injection 4 times/d (sham metoclopramide) or the active comparator 10 mg intravenous metoclopramide 4 times/d and a 1‐hour 0.9% saline infusion. After initial dosing, participants received a radiolabeled meal of liquid nutrient (Ensure; 106 kcal), and gastric emptying was measured (scintigraphy). Adverse events (AEs) were recorded from the time of consent through to day 5; serious AEs were collected to day 30. Results Thirteen patients (TAK‐954, n = 7; metoclopramide, n = 6) participated. Five patients in the TAK‐954 group and 4 in the metoclopramide group experienced AEs (2 and 3, respectively, were serious). All AEs except 1 (diarrhea in the metoclopramide group) were considered unrelated to study drug. Following treatment, a greater proportion of patients receiving TAK‐954 had normal gastric retention (<13% retention at 180 minutes) than those receiving metoclopramide (6/7 vs 3/6 patients, respectively). Conclusion A single dose of 0.5 mg intravenous TAK‐954 appears to have at least similar efficacy in accelerating gastric emptying to multiple doses of 10 mg metoclopramide and was not associated with increased AEs.
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Affiliation(s)
- Marianne J Chapman
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, South Australia, Australia.,Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Karen L Jones
- Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Cristina Almansa
- Takeda Development Center Americas, Inc., Cambridge, Massachusetts, USA
| | - Chris N Barnes
- Theravance Biopharma US, Inc., South San Francisco, California, USA
| | - Deanna Nguyen
- Theravance Biopharma US, Inc., South San Francisco, California, USA
| | - Adam M Deane
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Medicine, The University of Melbourne, Royal Melbourne Hospital, Melbourne, Victoria, Australia
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D'Souza RS, Mercogliano C, Ojukwu E, D'Souza S, Singles A, Modi J, Short A, Donato A. Effects of prophylactic anticholinergic medications to decrease extrapyramidal side effects in patients taking acute antiemetic drugs: a systematic review and meta-analysis. Emerg Med J 2018; 35:325-331. [PMID: 29431143 DOI: 10.1136/emermed-2017-206944] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2017] [Revised: 01/02/2018] [Accepted: 01/14/2018] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To determine the effectiveness of prophylactic anticholinergic medications in reducing extrapyramidal symptoms in patients taking acute antiemetics with a dopamine D2 receptor antagonist effect. METHODS Systematic searches of all published studies through March 2017 were identified from PubMed, Cochrane library, Embase, Web of Science and Scopus. Only randomised controlled trials of patients receiving dopamine D2 antagonist antiemetic therapy for acute migraine in which an anticholinergic or placebo was compared were included. Pooled ORs were calculated for incidence of extrapyramidal symptoms and sedation. RESULTS Four placebo-controlled randomised controlled trials consisting of 737 patients met the inclusion criteria for our meta-analysis. The effect of diphenhydramine differed depending on the method of administration of the antiemetic. When the antiemetic was delivered as a 2 min antiemetic bolus, the odds of extrapyramidal symptoms were significantly reduced in the diphenhydramine group compared with placebo (OR 0.42; 95% CI 0.22 to 0.81; P=0.01). However, when the antiemetic was given as a 15 min infusion, there was no significant difference in extrapyramidal symptoms with or without diphenhydramine (OR 1.06; 95% CI 0.58 to 1.91; P=0.85). The lowest incidence of extrapyramidal symptoms was observed in patients receiving a 15 min antiemetic infusion without diphenhydramine prophylaxis (9.8%). In two trials including 351 patients that dichotomously reported sedation scales, diphenhydramine had significantly higher rates of sedation (31.6%vs19.2%, OR 2.01, 95% CI 1.21 to 3.33; P=0.007). CONCLUSION Prophylactic diphenhydramine reduces extrapyramidal symptoms in patients receiving bolus antiemetic therapy with a dopamine D2 antagonist effect, but not when it is given as an infusion. Because of significantly greater sedation with diphenhydramine, the most effective strategy is to administer the D2 antagonist antiemetic as a 15 min infusion without prophylaxis.
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Affiliation(s)
- Ryan S D'Souza
- Department of Medicine, Reading Health System, West Reading, Pennsylvania, USA.,Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | | | - Elizabeth Ojukwu
- Department of Pediatrics, Vanderbilt University, Nashville, Tennessee, USA
| | - Shawn D'Souza
- Department of Neuroscience, University of Colorado, Boulder, Colorado, USA
| | - Andrew Singles
- Department of Medicine, Reading Health System, West Reading, Pennsylvania, USA
| | - Jaymin Modi
- Department of Medicine, Reading Health System, West Reading, Pennsylvania, USA
| | - Alexandra Short
- Department of Medicine, Reading Health System, West Reading, Pennsylvania, USA
| | - Anthony Donato
- Department of Medicine, Reading Health System, West Reading, Pennsylvania, USA
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Moisset X, Mawet J, Guegan-Massardier E, Bozzolo E, Gilard V, Tollard E, Feraud T, Noëlle B, Rondet C, Donnet A. French Guidelines For the Emergency Management of Headaches. Rev Neurol (Paris) 2016; 172:350-60. [PMID: 27377828 DOI: 10.1016/j.neurol.2016.06.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Accepted: 06/08/2016] [Indexed: 01/03/2023]
Affiliation(s)
- X Moisset
- Inserm U-1107, NeuroDol, Clermont Université, Université d'Auvergne, 49, boulevard François-Mitterrand, 63000 Clermont-Ferrand, France; CHU Gabriel Montpied, Service de Neurologie, Clermont Université, Université d'Auvergne, Clermont-Ferrand, France.
| | - J Mawet
- Centre d'urgences céphalées, département de Neurologie, GH Saint-Louis-Lariboisière, Assistance Publique des Hôpitaux de Paris AP-HP, Université Paris Denis Diderot et DHU NeuroVasc Sorbonne Paris-Cité, Paris, France
| | - E Guegan-Massardier
- Service de neurologie, hôpital Charles-Nicolle, 1, rue de Germont, 76000 Rouen, France
| | - E Bozzolo
- Service de neurologie, Pôle des Neurosciences Cliniques, CHU de Nice, Nice, France
| | - V Gilard
- Service de neurochirurgie, hôpital Charles-Nicolle, 1, rue de Germont, 76000 Rouen, France
| | - E Tollard
- Service de neuroradiologie, hôpital Charles-Nicolle, 1, rue de Germont, 76000 Rouen, France
| | - T Feraud
- Service d'accueil des urgences, hôpital Timone, boulevard Jean-Moulin, 264, rue Saint-Pierre, 13385 Marseille, France
| | - B Noëlle
- Cabinet privé, 35, allée de Champrond, 38330 Saint-Ismier, France
| | - C Rondet
- Faculté de médecine, Service de médecine générale, Université Pierre-et-Marie-Curie Paris 06, Paris, France
| | - A Donnet
- Inserm U-1107, NeuroDol, Clermont Université, Université d'Auvergne, 49, boulevard François-Mitterrand, 63000 Clermont-Ferrand, France; Centre d'évaluation et de traitement de la douleur, hôpital Timone, boulevard Jean-Moulin, 264, rue Saint-Pierre, 13385 Marseille, France
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Abstract
OBJECTIVE The aim of the study was to evaluate the safety and efficacy of a standardized pediatric migraine practice guideline in the emergency department (ED). METHODS Migraine Clinical Practice Guideline (MCPG) was created in collaboration with the Division of Pediatric Neurology and Pediatric Emergency Medicine. The MCPG was established on evidence-based data and best practice after a review of the literature. The MCPG was implemented for patients with a known diagnosis of migraine headaches and a verbal numeric pain score (VPS) greater than 6 on a 0 to 10 scale. Patients received intravenous saline, ketorolac, diphenhydramine, and either metoclopramide or prochlorperazine. After 40 minutes, another VPS was obtained, and if no improvement, a repeat dose of metoclopramide or prochlorperazine was administered. If after 40 minutes and minimal pain relief occurred, a consult to neurology was made. A chart review of patients enrolled in the MCPG from April 2004 to April 2013 was conducted. We recorded demographic data, vital signs, ED length of stay, initial VPS, last recorded VPS, adverse events, and admission rate. Nonparametric statistics were performed. RESULTS A total of 533 charts were identified with a discharge diagnosis of migraine headache of which 266 were enrolled in the MCPG (179 females and 87 males). Mean (SD) age was 13.9 (3.1). Mean (SD) initial VPS was 7.8 (2.0). Mean (SD) discharge VPS was 2.1 (2.8), representing a 73% reduction of pain. Twenty patients (7.5%) were admitted for status migrainosus; mean (SD) age was 14.0 (3.5) years and mean (SD) VPS was 6.3 (2.8). Mean (SD) length of stay in ED was 283 (107) minutes. No adverse events were identified. CONCLUSIONS Our MCPG was clinically safe and effective in treating children with acute migraine headaches. Our data add to the dearth of existing published literature on migraine treatment protocols in the ED setting. We recommend additional prospective and comparative studies to further evaluate the effectiveness of our protocol in this patient population.
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Wijemanne S, Jankovic J, Evans RW. Movement Disorders From the Use of Metoclopramide and Other Antiemetics in the Treatment of Migraine. Headache 2015; 56:153-61. [DOI: 10.1111/head.12712] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2015] [Indexed: 12/13/2022]
Affiliation(s)
- Subhashie Wijemanne
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine; Houston TX USA
| | - Joseph Jankovic
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine; Houston TX USA
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Kabbouche M. Management of Pediatric Migraine Headache in the Emergency Room and Infusion Center. Headache 2015; 55:1365-70. [PMID: 26486800 DOI: 10.1111/head.12694] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 08/11/2015] [Accepted: 08/11/2015] [Indexed: 11/30/2022]
Abstract
Migraine is a common disorder that starts at an early age and takes a variable pattern from intermittent to chronic headache with several exacerbations throughout a lifetime. Children and adolescents are significantly affected. If an acute headache is not aborted by outpatient migraine therapy, it often causes severe disability, preventing the child from attending school and social events. Treating the acute severe headache aggressively helps prevent prolonged disability as well as possible chronification. Multiple medications are available, mostly for the outpatient management of an attack and include the use of over-the-counter anti-inflammatory medications as well as prescribed medications in the triptan group. These therapies do sometime fail and the exacerbation can last from days to weeks. If the headache lasts 72 hours or longer it will fall in the category of status migrainosus. Status migrainosus is described as a severe disabling headache lasting 72 hours or more by the ICHD3 criteria. Disability is a major issue in children and adolescents and aggressive acute measures are to be taken to control it as soon as possible. Early aggressive intravenous therapy can be very effective in breaking the attack and allowing the child to be quickly back to normal functioning. This article reviews what is available for the treatment of pediatric primary headaches in the emergency room.
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Affiliation(s)
- Marielle Kabbouche
- Division of Neurology, University of Cincinnati College of Medicine, Cincinnati, OH, 45229-3039, USA (M. Kabbouche).,Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45229-3039, USA (M. Kabbouche)
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Cavero-Redondo I, Álvarez-Bueno C, Pozuelo-Carrascosa DP, Díez-Fernández A, Notario-Pacheco B. Risk of extrapyramidal side effects comparing continuous vs. bolus intravenous metoclopramide administration: a systematic review and meta-analysis of randomised controlled trials. J Clin Nurs 2015; 24:3638-46. [PMID: 26373874 DOI: 10.1111/jocn.12984] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2015] [Indexed: 10/23/2022]
Abstract
AIMS AND OBJECTIVES To provide evidence about whether intravenous metoclopramide continuous infusion is associated with fewer extrapyramidal side effects than bolus infusion. BACKGROUND Many studies have described the effects produced by the administration of metoclopramide, as a continuous intravenous infusion or intravenous bolus directly, but there is a lack of consensus about the best administration of this drug to minimise extrapyramidal side effects. DESIGN A meta-analysis was conducted. METHODS The search data base was conducted in: Cochrane Library, PubMed, Web of Knowledge and Scopus, to collect randomised controlled trials examining the association between extrapyramidal side effects and intravenous metoclopramide continuous or bolus infusion. Meta-analyses were conducted for the eligible randomised controlled trials by Comprehensive Meta-Analysis. Risk difference and 95% CIs were calculated with the Cochran's Q-statistic, and heterogeneity was assessed with the I(2) test. RESULTS Eleven randomised controlled trials were included. Meta-analysis showed that continuous intravenous infusion of metoclopramide produced less extrapyramidal side effects (8%; 95% CI, 5-11%; p < 0·001; I(2) = 65%). These improvements were particularly strong in studies scored ≥3 in the Jadad scale (12%; 95% CI, 3-24%; I(2) = 0%), in emergency patients (12%; 95% CI, 2-25%; I(2) = 0%), in patients who used concomitant drugs (9%; 95% CI, 5-12%; I(2) = 80%) and when observation (8%; 95% CI, 5-14%; I(2) = 69%) or analogue scale (7%; 95% CI, 1-13%; I(2) = 64%) were used to quantify the number of extrapyramidal reactions in patients. CONCLUSIONS Compared with bolus administration, continuous intravenous infusion of metoclopramide reduces the appearance of extrapyramidal side effects. RELEVANCE TO CLINICAL PRACTICE Continuous infusion is an effective intervention to reduce in patients discomfort caused by the extrapyramidal side effects of metoclopramide. Clinicians also reduce the time spent on alleviating these unwanted effects.
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Affiliation(s)
- Iván Cavero-Redondo
- Social and Health Care Research Center (CESS), University of Castilla La Mancha, Cuenca, Spain
| | - Celia Álvarez-Bueno
- Social and Health Care Research Center (CESS), University of Castilla La Mancha, Cuenca, Spain
| | | | | | - Blanca Notario-Pacheco
- Social and Health Care Research Center (CESS), University of Castilla La Mancha, Cuenca, Spain
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12
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Leow FHP, Knott JC, Hassan FA, Taylor DM, Udayasiri R. Risk and Severity of Akathisia Following Administration of Metoclopramide in the Emergency Department. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2015. [DOI: 10.1002/j.2055-2335.2006.tb00606.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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13
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van Zanten ARH, van der Meer YG, Venhuizen WA, Heyland DK. Still a Place for Metoclopramide as a Prokinetic Drug in Critically Ill Patients? JPEN J Parenter Enteral Nutr 2015; 39:763-6. [PMID: 25567783 DOI: 10.1177/0148607114567711] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Accepted: 11/20/2014] [Indexed: 12/26/2022]
Affiliation(s)
| | - Y Gert van der Meer
- Department of Hospital Pharmacy, Gelderse Vallei Hospital, Ede, The Netherlands
| | - Willem A Venhuizen
- Department of Hospital Pharmacy, Gelderse Vallei Hospital, Ede, The Netherlands
| | - Daren K Heyland
- Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada
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14
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van der Meer YG, Venhuizen WA, Heyland DK, van Zanten ARH. Should we stop prescribing metoclopramide as a prokinetic drug in critically ill patients? Crit Care 2014; 18:502. [PMID: 25672546 PMCID: PMC4331179 DOI: 10.1186/s13054-014-0502-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Regulatory agencies in North America and Europe recently re-evaluated the safety of metoclopramide. This re-evaluation resulted in recommendations and restrictions in order to minimise the risk of neurological and other adverse reactions associated with the use of metoclopramide. In the ICU, off-label prescription of metoclopramide is common. We have reviewed the evidence for safety, effectiveness and dosing of metoclopramide in critically ill patients. Furthermore, tachyphylaxis is addressed and alternatives are summarised. Finally, recommendations are presented not to abandon use of metoclopramide in ICU patients, because metoclopramide is considered effective in enhancing gastric emptying and facilitating early enteral nutrition.
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Affiliation(s)
- Y Gert van der Meer
- />Department of Hospital Pharmacy, Gelderse Vallei Hospital, Willy Brandtlaan 10, Ede, 6716 RP the Netherlands
| | - Willem A Venhuizen
- />Department of Hospital Pharmacy, Gelderse Vallei Hospital, Willy Brandtlaan 10, Ede, 6716 RP the Netherlands
| | - Daren K Heyland
- />Clinical Evaluation Research Unit, Angada 4, Kingston General Hospital, 76 Stuart Street, Kingston, ON K7L 2 V7 Canada
| | - Arthur RH van Zanten
- />Department of Intensive Care, Gelderse Vallei Hospital, Willy Brandtlaan 10, Ede, 6716 RP the Netherlands
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15
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Abstract
This chapter reviews the spectrum and mechanisms of neurologic adverse effects of commonly used gastrointestinal drugs including antiemetics, promotility drugs, laxatives, antimotility drugs, and drugs for acid-related disorders. The commonly used gastrointestinal drugs as a group are considered safe and are widely used. A range of neurologic complications are reported following use of various gastrointestinal drugs. Acute neurotoxicities, including transient akathisias, oculogyric crisis, delirium, seizures, and strokes, can develop after use of certain gastrointestinal medications, while disabling and pervasive tardive syndromes are described following long-term and often unsupervised use of phenothiazines, metoclopramide, and other drugs. In rare instances, some of the antiemetics can precipitate life-threatening extrapyramidal reactions, neuroleptic malignant syndrome, or serotonin syndrome. In contrast, concerns about the cardiovascular toxicity of drugs such as cisapride and tegaserod have been grave enough to lead to their withdrawal from many world markets. Awareness and recognition of the neurotoxicity of gastrointestinal drugs is essential to help weigh the benefit of their use against possible adverse effects, even if uncommon. Furthermore, as far as possible, drugs such as metoclopramide and others that can lead to tardive dyskinesias should be used for as short time as possible, with close clinical monitoring and patient education.
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Affiliation(s)
- Annu Aggarwal
- Center for Brain and Nervous System, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai, India
| | - Mohit Bhatt
- Center for Brain and Nervous System, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai, India.
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16
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Egerton-Warburton D, Povey K. Administration of metoclopramide by infusion or bolus does not affect the incidence of drug-induced akathisia. Emerg Med Australas 2013; 25:207-12. [DOI: 10.1111/1742-6723.12062] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2013] [Indexed: 01/17/2023]
Affiliation(s)
| | - Kirsty Povey
- Emergency Department; Dandenong Hospital; Melbourne; Victoria; Australia
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17
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Abstract
Migraine constitutes a relatively common reason for pediatric emergency room visits. Given the paucity of randomized trials involving pediatric migraineurs in the emergency department setting compared with adults, recommendations for managing these children are largely extrapolated from adult migraine emergency room studies and trials involving outpatient home pediatric migraine therapy. We review current knowledge about pediatric migraineurs presenting at the emergency room and their management, and summarize the best evidence available to guide clinical decision-making.
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Affiliation(s)
- Amy A Gelfand
- Division of Child Neurology, Department of Neurology, University of California, San Francisco, San Francisco, California, USA.
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18
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Simpson PM, Bendall JC, Middleton PM. Review article: Prophylactic metoclopramide for patients receiving intravenous morphine in the emergency setting: a systematic review and meta-analysis of randomized controlled trials. Emerg Med Australas 2011; 23:452-7. [PMID: 21824312 DOI: 10.1111/j.1742-6723.2011.01433.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The objective of the present study was to conduct a systematic review and meta-analysis of randomized controlled trials, comparing metoclopramide with placebo, for preventing vomiting in patients who have received i.v. morphine for acute pain in the emergency setting, and to determine the level of evidence supporting the use of prophylactic metoclopramide in this population. Comprehensive systematic electronic searches were conducted of MEDLINE, EMBASE and the Cochrane Library for randomized controlled trials addressing the clinical question. Reference lists of identified articles were hand-searched. Methodologically appropriate clinical trials identified in the search process were included in a meta-analysis to provide a pooled estimate of effect. Three randomized controlled trials fulfilled the search criteria. All three studies were included in the final meta-analysis that demonstrated an overall result of no difference between metoclopramide and placebo for the primary outcome of vomiting (odds ratios 0.72; 95% confidence intervals 0.11-4.58). There was little evidence that routine prophylactic administration of metoclopramide following the administration of i.v. morphine for acute pain management in the emergency setting is clinically beneficial. Routine metoclopramide administration might expose patients to a risk of harm which is not justifiable given a lack of evidence of benefit.
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Affiliation(s)
- Paul M Simpson
- Ambulance Research Institute, Ambulance Service of New South Wales, Rozelle, New South Wales, Australia.
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19
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Friedman BW, Mulvey L, Esses D, Solorzano C, Paternoster J, Lipton RB, Gallagher EJ. Metoclopramide for acute migraine: a dose-finding randomized clinical trial. Ann Emerg Med 2011; 57:475-82.e1. [PMID: 21227540 DOI: 10.1016/j.annemergmed.2010.11.023] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2010] [Revised: 11/05/2010] [Accepted: 11/11/2010] [Indexed: 12/25/2022]
Abstract
STUDY OBJECTIVE Intravenous metoclopramide is effective as primary therapy for acute migraine, but the optimal dose of this medication is not yet known. The objective of this study is to compare the efficacy and safety of 3 different doses of intravenous metoclopramide for the treatment of acute migraine. METHODS This was a randomized, double-blind, dose-finding study conducted on patients who presented to our emergency department (ED) meeting International Classification of Headache Disorders criteria for migraine without aura. We randomized patients to 10, 20, or 40 mg of intravenous metoclopramide. We coadministered diphenhydramine to all patients to prevent extrapyramidal adverse effects. The primary outcome was improvement in pain on an 11-point numeric rating scale at 1 hour. Secondary outcomes included sustained pain freedom at 48 hours and adverse effects. RESULTS In this study, 356 patients were randomized. Baseline demographics and headache features were comparable among the groups. At 1 hour, those who received 10 mg of intravenous metoclopramide improved by a mean of 4.7 numeric rating scale points (95% confidence interval [CI] 4.2 to 5.2 points); those who received 20 mg improved by 4.9 points (95% CI 4.4 to 5.4 points), and those who received 40 mg improved by 5.3 points (95% CI 4.8 to 5.9 points). Rates of 48-hour sustained pain freedom in the 10-, 20-, and 40-mg groups were 16% (95% CI 10% to 24%), 20% (95% CI 14% to 28%), and 21% (95% CI 15% to 29%), respectively. The most commonly occurring adverse event was drowsiness, which impaired function in 17% (95% CI 13% to 21%) of the overall study population. Akathisia developed in 33 patients. Both drowsiness and akathisia were evenly distributed across the 3 arms of the study. One month later, no patient had developed tardive dyskinesia. CONCLUSION Twenty milligrams or 40 mg of metoclopramide is no better for acute migraine than 10 mg of metoclopramide.
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Affiliation(s)
- Benjamin W Friedman
- Department of Emergency Medicine, Albert Einstein College of Medicine, Bronx, NY 10467, USA.
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20
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Erdur B, Tura P, Aydin B, Ozen M, Ergin A, Parlak I, Kabay B. A trial of midazolam vs diphenhydramine in prophylaxis of metoclopramide-induced akathisia. Am J Emerg Med 2010; 30:84-91. [PMID: 21159473 DOI: 10.1016/j.ajem.2010.10.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2010] [Revised: 09/28/2010] [Accepted: 10/09/2010] [Indexed: 11/19/2022] Open
Abstract
STUDY OBJECTIVE The study aimed to evaluate the effects of midazolam and diphenhydramine for the prevention of metoclopramide-induced akathisia. METHODS This randomized, double-blind, and controlled trial aimed to investigate coadministered midazolam vs diphenhydramine in the prophylaxis of metoclopramide-induced akathisia. Patients 18 to 65 years of age who presented to the emergency department with primary or secondary complaints of nausea and/or moderate to severe vascular-type headache were eligible for this study. Patients were randomized to one of the fallowing 3 groups: (1) metoclopramide 10 mg + midazolam 1.5 mg; (2) metoclopramide 10 mg + diphenhydramine 20 mg; (3) metoclopramide 10 mg + placebo. Metoclopramide was administered as a 2-minute bolus infusion. Midazolam, diphenhydramine, and normal saline solution were administered as a 15-minute slow infusion. The whole procedure was observed; and akathisia and sedation scores and vital changes were recorded. RESULTS There were significant differences among groups with respect to akathisia (P = .016) and sedation (P < .001). The midazolam group showed the lowest mean akathisia score but the highest mean sedation score. Akathisia scores of the diphenhydramine group were not different from placebo. There were significant differences among groups in terms of changes in mean vital findings such as respiration rates, pulse rates, and systolic blood pressures (P < .05). There were no significant difference among groups in terms of changes in mean diastolic blood pressures (P = .09). CONCLUSION Coadministered midazolam reduced the incidence of akathisia induced by metoclopramide compared to placebo but increased the rate of sedation. No difference was detected from diphenhydramine. Routine coadministered 20 mg diphenhydramine did not prevent metoclopramide-induced akathisia.
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Affiliation(s)
- Bulent Erdur
- Department of Emergency Medicine, Medical Faculty, Pamukkale University, 20070, Denizli, Turkey.
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21
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Patanwala AE, Amini R, Hays DP, Rosen P. Antiemetic Therapy for Nausea and Vomiting in the Emergency Department. J Emerg Med 2010; 39:330-6. [DOI: 10.1016/j.jemermed.2009.08.060] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2009] [Revised: 06/30/2009] [Accepted: 08/30/2009] [Indexed: 11/15/2022]
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22
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Dickerson RN, Mitchell JN, Morgan LM, Maish GO, Croce MA, Minard G, Brown RO. Disparate response to metoclopramide therapy for gastric feeding intolerance in trauma patients with and without traumatic brain injury. JPEN J Parenter Enteral Nutr 2010; 33:646-55. [PMID: 19892902 DOI: 10.1177/0148607109335307] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Patients with traumatic brain injury (TBI) have delayed gastric emptying and often require prokinetic drug therapy to improve enteral feeding tolerance. The authors hypothesized that metoclopramide was less efficacious for improving gastric feeding tolerance for trauma patients with TBI compared to trauma patients without TBI. A retrospective analysis was conducted of patients admitted to the trauma or neurosurgical intensive care unit who received gastric feeding from January 2006 to April 2008. Gastric feeding intolerance was defined by a gastric residual volume >200 mL or emesis with abdominal distension or discomfort. Patients with gastric feeding intolerance were given metoclopramide 10 mg intravenously every 6 hours, followed by a dose escalation to 20 mg, and then combination therapy with metoclopramide and erythromycin 250 mg intravenously every 6 hours if intolerance persisted. In total, 882 trauma patients (49% with TBI) were evaluated. TBI patients had a higher incidence of gastric feeding intolerance than those without TBI (18.6% vs 10.4%, P < or = .001). Efficacy rates for metoclopramide 10 mg, metoclopramide 20 mg, and metoclopramide-erythromycin were 55%, 62%, and 79%, respectively (P < or = .03). Metoclopramide failure occurred in 54% of patients with TBI compared to 35% of patients without TBI, respectively (P < or = .02), due to a greater prevalence of tachyphylaxis. Single-drug therapy with metoclopramide was less effective for TBI trauma patients compared to trauma patients without TBI. Combination therapy with erythromycin as first-line therapy for TBI trauma patients with gastric feeding intolerance is indicated if there are no contraindications or significant drug interactions.
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Affiliation(s)
- Roland N Dickerson
- Department of Clinical Pharmacy, University of Tennessee Health Science Center, Memphis, Tennessee 38163, USA.
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23
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Yeoh BSK, Taylor DM, Taylor SE. Education initiative improves the evidence-based use of metoclopramide following morphine administration in the emergency department. Emerg Med Australas 2009; 21:178-83. [PMID: 19527276 DOI: 10.1111/j.1742-6723.2009.01179.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE We aimed to evaluate a multifaceted education initiative designed to reduce the prophylactic use of metoclopramide. METHODS This was a pre- and post-intervention trial undertaken in a single ED. All ED doctors and nurses were targeted. The intervention comprised a specifically designed, 19-slide 'e-learning module', accessible via the ED intranet, supplemented by in-service training and a range of reminder techniques (posters, emails and drug room flyers). The primary end-point was the proportion of patients administered metoclopramide prophylactically with their initial morphine dose. Data were collected on random samples of patients who received morphine, using explicit medical chart review. RESULTS Both pre- and post-intervention periods were of 3 month duration. The charts of 146 cases were reviewed in each period. In the post-intervention period: * The proportion of patients administered metoclopramide prophylactically decreased from 22.6% to 4.1% (difference 18.5% [95% CI 10.3-26.7], P < 0.001) * The proportion of patients administered metoclopramide appropriately (for known morphine sensitivity, established nausea and rescue anti-emesis) rose marginally from 28.8% to 32.9% (difference 4.1% [95% CI -7.2-15.4], P = 0.53) * There was a 12.7% decrease in the number of ampoules of metoclopramide issued to the ED without a concurrent rise in the issue of other anti-emetic drugs CONCLUSION The education initiative resulted in a significant improvement in the evidence-based use of metoclopramide.
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24
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Slower infusion of metoclopramide decreases the rate of akathisia. Am J Emerg Med 2009; 27:475-80. [PMID: 19555621 DOI: 10.1016/j.ajem.2008.03.044] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2008] [Accepted: 03/31/2008] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE We investigated the difference in incidence of acute akathisia related to the rate of infusion in patients receiving metoclopramide for acute nausea, vomiting, or migraine headache in the emergency department (ED). METHODS Randomized, prospective, double-blind clinical trial of patients aged 18 years and older who were to receive intravenous metoclopramide for the treatment of nausea, vomiting, or headache were eligible. Patients were excluded if they were taking medications that might mimic or mask akathisia, had a movement disorder, renal insufficiency, or were unable or unwilling to consent. Pregnant women and prisoners were also excluded. Subjects were randomized to receive 1 of 2 accepted metoclopramide administration regimens. The regimens included 10 mg of metoclopramide administered either as a 2-minute bolus (BG) or as a slow infusion for 15 minutes (IG). All patients received a normal saline placebo at the opposite rate to maintain blinding. The main outcome was development of akathisia noted at 60 minutes after drug administration as measured either with The Prince Henry Hospital akathisia rating scale or by sudden unexplained departure from the ED during treatment. RESULTS One hundred twenty-seven patients were eligible for the study. Fifty-nine patients met exclusion criteria. Of the remaining 68 patients, 36 were randomized to the BG and 32 were randomized to the IG. In the BG, 11.1% of patients developed akathisia compared with 0% in the IG (P = .026). Four patients developed akathisia based on the scale and 2 departed suddenly from the ED. CONCLUSIONS Slower infusion of metoclopramide reduces the incidence of akathisia.
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25
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Friedman BW, Bender B, Davitt M, Solorzano C, Paternoster J, Esses D, Bijur P, Gallagher EJ. A Randomized Trial of Diphenhydramine as Prophylaxis Against Metoclopramide-Induced Akathisia in Nauseated Emergency Department Patients. Ann Emerg Med 2009; 53:379-85. [DOI: 10.1016/j.annemergmed.2008.08.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2008] [Revised: 07/17/2008] [Accepted: 08/01/2008] [Indexed: 10/21/2022]
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26
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Friedman BW, Esses D, Solorzano C, Dua N, Greenwald P, Radulescu R, Chang E, Hochberg M, Campbell C, Aghera A, Valentin T, Paternoster J, Bijur P, Lipton RB, Gallagher EJ. A Randomized Controlled Trial of Prochlorperazine Versus Metoclopramide for Treatment of Acute Migraine. Ann Emerg Med 2008; 52:399-406. [DOI: 10.1016/j.annemergmed.2007.09.027] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2007] [Revised: 08/28/2007] [Accepted: 09/21/2007] [Indexed: 12/27/2022]
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27
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Metoclopramide and Extrapyramidal Symptoms: A Case Report. J Perianesth Nurs 2008; 23:292-9. [DOI: 10.1016/j.jopan.2008.07.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2007] [Revised: 06/04/2008] [Accepted: 07/13/2008] [Indexed: 11/21/2022]
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