TY - JOUR
AU - Ross, Jamie
AB - Sir, There are many reports in the literature describing metoclopramide‐induced movement disorders by oral or intravenous routes, with or without renal failure, but this has never been described by intraperitoneal use. Gastroparesis, nausea and vomiting are commonly encountered in patients using continuous ambulatory peritoneal dialysis (CAPD) for the management of end‐stage renal disease (ESRD). Patients with gastroparesis usually experience an improvement in their symptoms using oral prokinetic medications, such as metoclopramide, cisapride, domperidone and eythromycin [1]. Unfortunately, some patients are unable to tolerate oral therapy and ultimately use the intraperitoneal route for symptomatic relief. With the recent restricted use of cisapride (US brand name Propulsid®), treatment options for symptomatic patients using CAPD are limited. Case A 40‐year‐old female was admitted with a 1‐day history of dysarthria, agitation, confusion and diffuse muscle weakness. She had a history of end‐stage renal disease and had been on peritoneal dialysis for the last 2 years. For her documented gastroparesis, which was refractory to oral metoclopramide, she had been instilling into her peritoneal dialysate (2.5% Dianeal®) 42 mg of metoclopramide daily. This regimen had been successful in alleviating her symptoms of nausea and abdominal fullness for 8 months. One week prior to admission her symptoms worsened and the patient increased her daily dose of metoclopramide to 70 mg metoclopramide. The patient demonstrated diffuse bradykinesia, upper extremity cogwheel rigidity and dysarthria. A fine resting tremor of both hands was also noted. Laboratory data was remarkable for a serum creatinine of 12.1 mg/dl. Computed tomography of the head was normal. The patient was diagnosed with a probable metoclopramide‐induced dystonic reaction and was given diphenhydramine 25 mg i.v., resulting in near‐complete resolution of her dysarthria and muscle weakness within 5 min. Metoclopramide was discontinued and she was started on a scheduled dose of diphenhydramine 50 mg i.v. three times a day, and benztropine 1 mg p.o. twice a day. Fortunately the patient did not have any recurrence of her movement disorder after hospital discharge. Comment It is estimated that about half of diabetic and non‐diabetic patients with ESRD undergoing CAPD have nausea, vomiting and delayed gastric emptying [2]. Treatment of symptomatic CAPD patients is often disappointing after dietary and oral prokinetic medications have failed. Metoclopramide (US brand name Reglan®) is a commonly prescribed antiemetic, peristaltic and antinauseant that has become the treatment of choice for gastroparesis, followed by domperidone and erythromycin. Unfortunately, intraperitoneal route, dose and efficacy of prokinetic medications is limited to occasional case reports. Metoclopramide used in renal failure has been a subject of interest since the 1970s when the first documented extrapyramidal syndromes arose in patients with glomerular filtration rates <10 ml/min [3]. The dosing of metoclopramide in patients using CAPD is unknown, but in severe renal insufficiency (glomerular filtration rate <10 ml/min), an oral or intravenous dose reduction of 50–67% is recommended [4]. In addition, it has been suggested that drug‐induced movement disorders may occur less frequently when the drug is delivered in more dilute concentrations and at slower rates [5]. Early recognition is essential in the treatment of metoclopramide‐induced movement disorders. If metoclopramide is clearly indicated in refractory cases, we recommend extremely reduced intraperitoneal doses at slower rates. Also, further research and larger, controlled studies on the intraperitoneal use of metoclopramide and other prokinetic medications such as domperidone and erythomycin are needed. Email: fhusserl@ochsner.org References 1 Hasler WL. Disorders of gastric emptying. In: Yamada T, Alpers DH, Laine L et al., eds. Textbook of Gastroenterology , 3rd edition, Chapter 63. Lippincott Williams and Wilkins, Philadelphia, Pennsylvania, 1999; 1341–1369 Google Scholar 2 Bird NJ, Streather CP, O'Doherty MJ et al. Gastric emptying in patients with chronic renal failure on continuous ambulatory peritoneal dialysis. Nephrol Dial Transplant  1993; 9: 287–290 Google Scholar 3 Caralps A. Metoclopramide in renal failure [letter]. Lancet  1979; I: 554 Google Scholar 4 Seyffart G. Drug Dosing in Renal Failure . Kluwer Academic Publishing, The Netherlands, 1991 Google Scholar 5 Beightol RW, Coupal JJ, Shih W. Prevention of metoclopramide‐induced akathisia during gastric emptying imaging. J Nucl Med  1991; 32: 1644–1645 Google Scholar © European Renal Association–European Dialysis and Transplant Association
TI - Intraperitoneal metoclopramide causing a movement disorder
JF - Nephrology Dialysis Transplantation
DO - 10.1093/ndt/17.5.945
DA - 2002-05-01
UR - https://www.deepdyve.com/lp/oxford-university-press/intraperitoneal-metoclopramide-causing-a-movement-disorder-oac4lj2fK8
SP - 945
EP - 945
VL - 17
IS - 5
DP - DeepDyve
ER -