Intravenous administration of metoclopramide by 2 min bolus vs 15 min infusion: does it affect the improvement of headache while reducing the side effects?

Abstract

Objective: To determine the therapeutic effect (alleviation of vascular type headache) and side effects of a slow intravenous metoclopramide infusion over 15 min compared with those effects of a bolus intravenous metoclopramide infusion over 2 min in the treatment of patients with recent onset vascular type headache. Material and methods: All adults treated with metoclopramide for vascular type headache were eligible for entry into this clinical randomised double blinded trial. This study compared the effects of two different rates of intravenous infusion of metoclopramide over a period of 13 months at a university hospital emergency department. During the trial, side effects and headache scores were recorded at baseline (0 min), and then at 5, 15, 30 and 60 min. Repeated measures analysis of variance was used to compare the medication's efficacy and side effects. Results: A total of 120 patients presenting to the emergency department met the inclusion criteria. Of these, 62 patients (51.7%) were given 10 mg metoclopramide as a slow intravenous infusion over 15 min (SIG group) and 58 patients (48.3%) were given 10 mg metoclopramide intravenous bolus infusion over 2 min (BIG group). 17 of the 58 patients in the BIG group (29.3%) and 4 of the 62 patients (6.5%) in the SIG group had akathisia (p = 0.001). There were no significant differences between the BIG and SIG groups in terms of mean headache scores (p = 0.34) and no adverse reactions in the study period. Metoclopramide successfully relieved the headache symptom(s) of patients in both the BIG and SIG groups. Conclusion: Slowing the infusion rate of metoclopramide is an effective strategy for the improvement of headache and reducing the incidence of akathisia in patients with vascular type headache.

Slow infusion metoclopramide does not affect the improvement rate of nausea while reducing akathisia and sedation incidence

“…In both groups we observed that on average, in the fifth minute, the nausea scores decreased to half. The results of this study are similar in some aspects to previous ones 2 9 10 12 19 20…”

“…In the studies in which bolus infusion administrations of metoclopramide were compared, which were sufficient in terms of sampling, and were prospective, randomised, double blind trials, it was observed that slow infusion significantly reduced the percentage of akathisia 2 3 9 10 12 20 21. Akathisia can go unnoticed by physicians, especially in busy EDs.…”

“…Sedation was found to be the most common side effect; among 85 patients given a 10 mg intravenous bolus of metoclopramide, 17 showed sedation, which is similar to our findings. In another study, Parlak et al 9 compared the slow and bolus application of metoclopramide in the treatment of headaches and recorded the side effects. Although the ratios were not provided, sedation was observed much more in the bolus infusion group than in the slow infusion group.…”

“…The most common extrapyramidal side effect is akathisia which is most often manifest as continuous movement, usually of the lower extremities, and associated anxiety 6–8. In the literature, the frequency of akathisia after the administration of 10 mg of metoclopramide as an intravenous bolus to patients without premedication ranges from 20% to 25% 9. An effective strategy to decrease the incidence of akathisia is to slow down the speed of infusion of metoclopramide in patients suffering from nausea–vomiting 6 9–11.…”

Antiemetic Therapy for Nausea and Vomiting in the Emergency Department

“…Also, metoclopramide given as an infusion over 15 min is less likely to cause akathisia than if the same dose is given as a bolus over 2 min (5.8% vs. 24.7%, respectively; p Ͻ 0.001) (43). This observation is replicated in another study in patients with headache that reported a 78% relative risk reduction of akathisia with an infusion over 15 min (44). There was no loss of efficacy with regard to symptom relief by slower administration in these investigations.…”