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- Sep 24, 2024
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Metoclopramide in Your SN Protocol: A Safe Choice or a Risky Gamble?
Fact vs. Fear: Clarifying Misconceptions Around Meto, An Evidence-Based Approach
Fact vs. Fear: Clarifying Misconceptions Around Meto, An Evidence-Based Approach
In this post, I am going to explore the safety of metoclopramide (aka meto) in light of the perceived risks many have around taking it, in particular to those believing it might cause some immediate, severe side effect which would impair their ability to complete their SN Protocol or have lasting effects if they decide to not ingest SN after taking meto (absolutely fine to abort the attempt). We will go over the background of the medication, common doses to as compared to the SN dosing, discuss the likelihood of side effects, the causes of the negative reputation it has, and ultimately make the reasonable conclusion that including it in an SN Protocol (or other stat usage) is not very likely to cause any serious adverse reaction. There are always exceptions to this generality, so be sure to consider your own medical situation and assess it in that context. For purposes of this post we are going to be focusing on oral (vs IM or IV) usage of metoclopramide given that is the route used in the SN Protocols.
For example, here are some posts of people who have expressed concern about meto and the side effects or harm from taking it: [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21].
Background On the Medication: Oral metoclopramide (Reglan, Maxolon, Perinorm, Metozolv ODT) is frequently prescribed for various gastrointestinal conditions, typically at doses ranging from 5 mg to 20 mg per dose with the standard maximum daily dose for most indications is 40 mg. However, for specific conditions such as gastroesophageal reflux disease (GERD), may recommend a higher maximum daily dose of 60 mg. In addition to GERD, metoclopramide is commonly used for a variety of other conditions. These include nausea and vomiting associated with chemotherapy (10mg is the usual oral single dose), radiotherapy, and postoperative recovery. On rare occasion in the emergency department it is also used 'off label' for migraine. Although, it is not a frontline pick for migraines and typically for this use case it would be an IV dose, not an oral dose.
The medication acts as a dopamine D2 receptor antagonist and prokinetic, which enhances gastric motility and accelerates gastric emptying. By inhibiting these receptors, metoclopramide not only enhances gastric motility but also produces antiemetic effects by acting on serotonin 5-HT3 receptors in the chemoreceptor trigger zone (CTZ) located in the area postrema of the brain. It causes prokinetic effects through a combination of actions: it inhibits presynaptic and postsynaptic D2 receptors, agonizes serotonin 5-HT4 receptors, and antagonizes muscarinic receptor inhibition. This interaction enhances the release of acetylcholine, which increases the tone of the lower esophageal sphincter (LES) and gastric tone, effectively accelerating gastric emptying and transit through the gut. In essence, meto counteracts the relaxant effects of dopamine on the gastrointestinal tract, promoting smoother movement of food and reducing feelings of nausea. This mechanism of action makes it particularly effective for treating conditions like diabetic gastroparesis and functional dyspepsia (10-20mg is a typical single, oral dose for that usage).
However, despite these typical guidelines, higher oral doses of metoclopramide, such as 50 mg and 100 mg and some upwards of 2-3mg/kg, have been evaluated in clinical contexts, particularly for postoperative nausea and vomiting (PONV).
SN Context Using 30 mg Dosing: A 30 mg dose is not truly that significantly higher than typical clinical doses, which often range from 10 mg to 20 mg and is below the threshold of some studies evaluating high-dose usage. Medications are designed to be overly safe, especially when considering that many people inadvertently double dose their medication having forgotten they took it or been confused by directions such as "Take 10mg three/four times per day" and inadvertently takes 3-4 tablets all at once, not realizing it was intended to be spread out. Or forgetting they took a 15mg already then took another 15mg? We would have substantial data and significant number of reports of serious side effects from those who did accidentally take more than they intended if it was truly a widespread issue. Imagine if someone who took a double oral dose of this medication were at all likely to suffer from quick, serious side effect?! The outrage would lead to it getting pulled from market.
- Trial Data on Higher Oral Dosing than SN Protocol: A study that evaluated 50-100 mg doses found that about 9% of participants reported dystonia, indicating a relatively low rate of side effects even at doses higher than the SN Protocols. This greatly suggests the assertion I made earlier that the 30mg dose prior to SN is safe, effective, and not likely to yield any negative result that would impact the ability to finish the protocol.
- There could always be the rare exception, especially if elderly or diabetic, however the data simply does not support this being something to be truly concerned about. And yes, there is still a chance of a side effect happening; that is always a possibility. Is it likely to kick in before taking the SN and somehow interfere with your ability to succeed? No.
- Tardive Dyskinesia (TD): TD is more common with long-term use, with an incidence of 0.5% to 1%. Previous data provided a 1%-10% risk per national guidelines. Low dose for SN protocol or 30mg stat is not very likely to cause this side effect. Note, the word "tardive" specifically means "delayed reaction" so the symptom is not going to materialize right away anyways. Even if following a 48-hour regimen, the chances are still outstandingly low.
- Dystonia: Very rare, and occurs in about 0.1% to 0.2% of patients.
- Sedation and Fatigue: Found in 10% to 15% of patients. Not likely to make any noticeable difference for SN Protocol, especially if benzos are used. And once SN begins to work for CTB, there would be little to no attribution of this side effect to the metoclopramide.
- Gastrointestinal Effects: Diarrhea occurs in 2% to 5% of users, although some have reported abdominal cramping in the 5% to 10% range.
- Headache: A moderately common complain with different reports saying around 10% (1 in 10).
- Neuroleptic Malignant Syndrome (NMS): Outstandingly rare reaction with an incidence of less than 0.01%.
- Other: Allergic Reactions such as skin rash, itching, or swelling, though this is uncommon; cardiovascular effects such as irregular heartbeats or changes in blood pressure can occur but are rare. If you have underlying health issues, then this may be a possible concern. But if your body is sensitive or has known problems with medications, then it's likely not just this drug that would be at play to be worrisome in general. You know your own health situation better, and this is just a broad stroke discussion.
- Additionally, I have yet to come upon any medical journal cases of TD, dystonia or akathisia aka EPS (extrapyramidal symptoms) from any single, oral dose of metoclopramide, even at a higher dose. On this site, one user did express they experienced some side effects [1] a few hours after taking meto including seeming EPS and another user expressing akathisia symptoms [2] Another member said they experienced dystonia from meto but was their first and only post (unreliable anecdote) on this site [3]. However, that or any other accounts seem to be extremely few and far between. You can make your own decision based on research if this a mild concern for you and I am not going to evaluate the pros/cons of stat vs 48-hour regimen as the reasonable conclusion that in either protocol is that it is not likely to happen. Yes, you can probably find some single, one-off horror stories. Those should be considered just that.
- The medication begins to take effect within 30 to 60 minutes, with peak effects occurring around 1 to 2 hours post-dose with most side effects from metoclopramide typically manifesting within 24 to 72 hours after administration. Given what the protocol here is for SN, the chances of developing any serious side effects from metoclopramide before ingesting SN, or during the time SN is working for CTB is outstandingly, exceedingly low. This is especially the case if one is going for the "stat dose." There would be little to no ability to differentiate any possible side effects in light of taking SN (such as for example, headache) and could not be attributable to the use metoclopramide even if the onset of the side effect did happen that quickly.
About that Scary Black Box Warning: Prior to 2018, estimates suggested there were around 1,000 claims filed from 2005 to 2010, with many involving patients alleging they developed TD after long-term use. The black-box warning for Reglan that came out in 2009 was largely a response to those lawsuits about tardive dyskinesia. It was designed to make sure doctors and patients are aware of the risks involved. While it's super important for safety, it can also make people think that metoclopramide is way more dangerous than it actually is. In reality, for short periods the risks are outstandingly low (even at a 30mg stat dosing, which is anywhere from 2-3x higher than the prescribed clinical use, as discussed above). It's just one of those situations where the warning, to mitigate liability for the manufacturer, can create a bit of unnecessary fear around the medication.
What do Studies About it Show?: A retrospective study from the UK reported that out of 15.9 million prescriptions, only 455 cases of dystonia and 4 cases of tardive dyskinesia were documented (70% were female), indicating a very low incidence relative to the extensive use of the drug. That is about 1 in 34,966. Other studies have side effects way higher suggesting about 1:500 but note this is for any adverse reaction (headache, diarrhea, fatigue, etc). To put this in context for SN, SN itself can and does cause headache, fatigue, and so identifying the difference in what is caused by Metoclopramide over the SN itself is somewhat impossible. Again, given the timing this would be taken before the SN, it is very unlikely any slight chance of a side effect would impair the ability to complete this method.
Perspective on Number of Prescriptions vs Serious Side Effects: Between 2013-2018, ~1.8 million prescriptions were given for metoclopramide annually in the United States alone. In 2018, there were significant legal settlements involving metoclopramide, including around 1,700 cases, bringing a lot of public concern over side effects and their associated risks due to the visibility of the lawsuits. This caused a dip in the annual prescriptions, followed by a dip in 2020; however, by 2022 the annual prescription number increased to ~1.3 million. These lawsuits have primarily involved claims of tardive dyskinesia and other neurological effects, which skewed public perception of the drug's safety. Even if every single one of those cases had definitive proof of this side effect (and let's assume they do), taken contextually for the millions of prescriptions given, we can see just how exceedingly rare it is. If more people truly experienced this, we would have seen significantly more litigants especially in America which is notoriously 'sue happy'.
Let's compare this a little bit with another popular AE for SN Protocols: Domperidone (Motilium). This is going to be a very short discussion just to add a little context and I encourage anyone to do their own additional research, here I am just going to make some broad stroke considerations to hopefully make the point quickly. Like metoclopramide, domperidone is a dopamine D2 receptor antagonist and prokinetic. It is banned in the United States due to risk of cardiac events for general use*, yet remains available in many other countries (UK, Canada, EU, elsewhere). It remains available in the United States as a medication under expanded access for gastrointestinal mobility However, it is also important to remember this: Domperidone was never approved in the US for general use to begin with anyways. Studies indicated that *Domperidone could increase the risk of serious heart issues, including arrhythmias and sudden cardiac arrest, especially in higher doses or in patients with preexisting heart conditions. In 2004, the FDA issued a warning about the potential cardiac risks associated with Domperidone for women taking it for milk production. In 2014, it was formally prohibited from being sold in the U.S., primarily due to these safety concerns particularly among cancer patients who had been prescribed it for nausea and vomiting. Does this mean domperidone is severely dangerous and is going to cause this? Perhaps if you have heart issues. Or are a cancer patient. Or maybe a breast-feeding mother. Even then, it is just an increased risk, not a categorical reaction you will experience. Its ban in the U.S. was primarily due to concerns about serious cardiac risks, especially when compared to its relatively limited use. Meaning it was easier to ban a drug that did not even have general approval for use anyways than spend time, money, and research into its safety than to keep it on the market in America.
Ultimately, in weighing the evidence, it appears that while there are risks associated with metoclopramide, particularly with long-term use, the actual incidence of serious side effects remains relatively low. I may not have covered every single concern around this but tried to take a birds-eye view on this discussion to help set aside the concerns. Keep in mind that the usage of this medication for these protocols is outstandingly brief (further reduced for the Stat Protocol) so the likelihood of them happening in the timeframe before using SN is already outstandingly low. Given the usage in an SN protocol is brief, not outrageously above the 'normal' therapeutic dose, lack of time for side effects to even materialize, it absolutely is a 'safe' addition to the protocol and users should not be concerned around its limited usage here. The lawsuits and subsequent black-box warnings have contributed to a heightened perception of risk, which do not fully align with the clinical realities and millions upon millions of users and doses taken over the decades it has been used.
Hopefully this puts some ease and comfort around the usage of metoclopramide for anyone who had concern around it now that we are a little bit more armed with the facts and about this medication.
