Published: 2 March 2023

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Metoclopramide: risk of dystonic side effects in children and young adults

Published: 2 March 2023
Prescriber Update 44(1): 8–10
March 2023

The Centre for Adverse Reactions Monitoring (CARM) has received several reports recently of dystonic reactions in children prescribed metoclopramide. This article is a reminder that due to the risk of dystonic side effects, metoclopramide use in children and young adults is limited to certain conditions and for second-line therapy.

Metoclopramide

Metoclopramide is an antiemetic medicine indicated for the treatment of nausea and vomiting and digestive disorders.^1-3 Metoclopramide is a dopamine receptor antagonist.⁴ It is classified as a cholinomimetic because it increases the transmission of acetylcholine at muscarinic receptors.⁵

In New Zealand, metoclopramide is available as tablets and as a solution for injection.^1,6

Metoclopramide can cause dystonic side effects, which occur in approximately 1% of patients.¹ Dystonia can occur following a single dose of metoclopramide and occurs more frequently in children and young adults.¹

Conditions

Due to the risk of dystonic side effects, metoclopramide use in children and young adults (aged 1 to 19 years, inclusive) is limited to certain conditions and as second-line therapy,^1,6 as shown in Table 1. Note that the tablets are only indicated for young adults aged 15 to 19 years.

Table 1: Metoclopramide – conditions for use in children and young adults, by dose form

Dose form	Age	Conditions
Solution for injectiona,b	1 to 19 years (inclusive)	Second-line therapy for: severe intractable vomiting of known cause vomiting associated with radiation therapy or intolerance to cytotoxic drugs assisting in small bowel intubation
Tabletc	15 to 19 years (inclusive)	Second-line therapy for: severe intractable vomiting of known cause vomiting associated with radiation therapy and intolerance to cytotoxic medicines aiding gastrointestinal intubation premedication before surgical procedures

Notes:

1. Pfizer New Zealand Limited. 2021. Metoclopramide Injection New Zealand Data Sheet 9 July 2021. URL: medsafe.govt.nz/profs/Datasheet/m/Metoclopramidepfizerinj.pdf (accessed 17 January 2023).
2. Baxter Healthcare Ltd. 2019. Metoclopramide-Baxter New Zealand Data Sheet 7 November 2019. URL: medsafe.govt.nz/profs/Datasheet/m/MetoclopramideClarisinj.pdf (accessed 17 January 2023).
3. Teva Pharma (New Zealand) Limited. 2017. Metoclopramide Actavis New Zealand Data Sheet 22 May 2017. URL: medsafe.govt.nz/profs/Datasheet/m/MetoclopramideActavistab.pdf (accessed 17 January 2023).

Dystonia

Dystonia is a movement disorder. It involves uncontrolled muscle contractions, which can cause abnormal body movements such as repetitive movements or parts of the body twisting in unusual ways.^7,8 Dystonic movements also typically have a pattern and may be continuous or intermittent.⁷ Dystonia can affect a person’s whole body or one part of the body.⁸ Dystonic side effects are the most common type of extrapyramidal side effects associated with the use of metoclopramide.^4,5 As well as occurring more frequently in children and young adults, dystonic side effects associated with the use of metoclopramide have been reported as occurring more frequently in females than males and with higher doses.⁴ To reduce the risk of dystonic side effects, strictly follow the dose recommendations in the data sheets.^1,6

New Zealand case reports

As of 1 December 2022, the Centre for Adverse Reactions Monitoring had 372 reports relating to metoclopramide. Of these, 23% (86 reports) were in patients aged 19 years and under. Most of the 372 metoclopramide reports involved females (77%). Of the 86 reports in patients aged 19 years and under, 83% were in females. Dystonia was the most frequently reported adverse reaction associated with metoclopramide. Table 2 shows the top 5 reactions reported for metoclopramide in children and young adults (aged 19 years and under).

Table 2: Top 5 reactions reported for metoclopramide in children and young adults (≤19 years), as of 1 December 2022

Adverse drug reaction	Number of reports
Dystonia	44
Oculogyric crisis	14
Extrapyramidal disorder	8
Anxiety	5
Trismus	4

Source: Centre for Adverse Reactions Monitoring

More information

See the sponsors’ data sheets and Consumer Medicine Information (CMI) published on the Medsafe website.

• Search for a data sheet or CMI

References

1. Teva Pharma (New Zealand) Limited. 2017. Metoclopramide Actavis New Zealand Data Sheet 22 May 2017. URL: medsafe.govt.nz/profs/Datasheet/m/MetoclopramideActavistab.pdf (accessed 16 January 2023).
2. New Zealand Formulary (NZF). NZF v.127: Metoclopramide hydrochloride 1 January 2023. URL: nzf.org.nz/nzf_2384 (accessed 16 January 2023).
3. New Zealand Formulary for Children (NZFC). NZFC v.127: Metoclopramide hydrochloride 1 January 2023. URL: nzfchildren.org.nz/nzf_2384 (accessed 24 January 2023).
4. Tianyi F-L, Agbor VN and Njim T. 2017. Metoclopramide induced acute dystonic reaction: A case report. BMC Research Notes 10(1): 32. DOI: 10.1186/s13104-016-2342-6 (accessed 16 January 2023).
5. Chaudhary R, Malla G and Kadayat M. 2021. Metoclopramide-induced acute dystonic reactions: A case report. Journal of Medical Case Reports 15(1): 520. DOI: 10.1186/s13256-021-03110-y (accessed 16 January 2023).
6. Pfizer New Zealand Limited. 2021. Metoclopramide Injection New Zealand Data Sheet 9 July 2021. URL: medsafe.govt.nz/profs/Datasheet/m/Metoclopramidepfizerinj.pdf (accessed 17 January 2023).
7. Deik A, Comella, C. 2022. Etiology, clinical features, and diagnostic evaluation of dystonia. In: UpToDate 13 December 2022. URL: uptodate.com/contents/etiology-clinical-features-and-diagnostic-evaluation-of-dystonia (accessed 16 January 2023).
8. NHS. 2021. Dystonia 1 March 2021. URL: nhs.uk/conditions/dystonia/ (accessed 16 January 2023).