NEW ZEALAND DATA SHEET

1. PRODUCT NAME
Metoclopramide Injection Ampoule

2. QUALITATIVE AND QUANTITATIVE COMPOSITION

Metoclopramide Injection contains metoclopramide hydrochloride monohydrate 10.54 mg/2 mL,

equivalent to metoclopramide hydrochloride 10 mg/2 mL.

For the full list of excipients, see section 6.1.

3. PHARMACEUTICAL FORM
Solution for Injection.
Metoclopramide Injection is a clear, colourless, sterile, preservative-free solution.

4. CLINICAL PARTICULARS

4.1 Therapeutic indications

Adults (20 years and over)

• Relief of nausea and vomiting associated with migraine, cancer therapy (chemotherapy or radiation),
malignant disease, labour, infectious disease and uraemia
• Control of post-operative vomiting
• Assist in small bowel intubation
Metoclopramide is of little benefit for the prevention or treatment of motion sickness.

Young Adults and Children (over 1 year of age)

Metoclopramide should be restricted to the following conditions and only used as second line therapy,
when used to treat children and young adults under 20 years of age because of the risk of adverse effects:
• Severe intractable vomiting of known cause
• Vomiting associated with radiation therapy or intolerance to cytotoxic drugs
• Assist in small bowel intubation

4.2 Dose and method of administration

The dosage recommendations should be strictly adhered to in order to minimise the possibility of
dystonic side effects. Metoclopramide should only be used after careful examination has excluded any
underlying disorder (such as cerebral irritation) that may have induced nausea and vomiting.

Total daily doses of metoclopramide should not normally exceed 0.5 mg/kg bodyweight with a
maximum of 30 mg daily. This should be less (if possible) in children and young adults, when given
by injection. Maximum recommended treatment duration is 5 days in all age groups.

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Usual dosage is as follows and should be administered intramuscularly or by slow intravenous injection
over 1 to 2 minutes.

Adults
20 years and over: Maximum of 10 mg three times a day.

Young Adults
Treatment of young adults should commence at the lower dosage, and used as second line therapy only.
15 - 19 years: 5 mg to 10 mg three times a day.

Children
Treatment of children should commence at the lower dosage, where stated, and used as second line
therapy only.
5 - 14 years: 2.5 mg to 5 mg three times a day.
3 - 5 years: 2 mg two to three times a day.
1 - 3 years: 1 mg two to three times a day.

Diagnostic Indications
A single dose of metoclopramide may be given 5 to 10 minutes before the examination. Subject to
bodyweight considerations, the following dosages are recommended:

Adults
20 years and over: 10 mg to 20 mg

Young Adults
15 - 19 years: 10 mg

Children
9 - 14 years: 5 mg
5 - 9 years: 2.5 mg
3 - 5 years: 2 mg
1 - 3 years: 1 mg

Use in Special Patient Populations

Elderly Patients
To avoid adverse reactions strict adherence to dosage recommendations is advised and, where prolonged
therapy is considered necessary, patients should be regularly reviewed.

Patients with Renal Impairment

Since metoclopramide is excreted principally through the kidneys, in those patients whose creatinine
clearance is below 40 mL/min, therapy should be initiated at approximately one-half the usual dose.
Subsequent dosage will depend on individual clinical response.

Patients with Hepatic Impairment

Metoclopramide undergoes hepatic metabolism via simple conjugation. Its safe use has been described
in patients with advanced liver disease whose renal function was normal. It is suggested that therapy
be initiated as half the recommended dose with subsequent dose adjustment being made as the individual
response has been determined.

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Compatibility

Intravenous Fluids
No preservative is included in the formulation of Metoclopramide Injection. Therefore, to reduce
microbiological hazard, admixture to intravenous fluids should be performed under aseptic conditions
and the infusion commenced as soon as possible after preparation and in any case within 24 hours of
preparation. If storage is necessary, keep at 2°C to 8°C.

The literature indicates that Metoclopramide Injection may be added to the following solutions:
• Glucose 5% in sodium chloride 0.45%
• Glucose 5% in water
• Mannitol 20%
• Sodium chloride 0.9%
• Ringer's injection
• Ringer's injection, lactated (Hartmann’s solution)

Narcotic Analgesics
• Morphine sulfate: 1 mg/mL with metoclopramide hydrochloride 0.2 mg/mL in glucose 5% in water
visually compatible for a 4 hour study period at 25°C under fluorescent light.
• Pethidine hydrochloride: 10 mg/mL with metoclopramide hydrochloride 0.2 mg/mL in glucose 5%
in water visually compatible for a 4 hour study period at 25°C under fluorescent light.

Cytotoxic Drugs
If the standard formulation of metoclopramide is used for the treatment of nausea and vomiting
associated with cytotoxic drugs, the cytotoxic agent should be administered as a separate infusion.

4.3 Contraindications

• Patients in whom increased gastrointestinal motility might be dangerous, e.g. presence of

gastrointestinal haemorrhage, mechanical obstruction or perforation
• Phaeochromocytoma due to the possibility of a hypertensive crisis, probably due to release of
catecholamines from the tumour
• Known hypersensitivity or intolerance to metoclopramide. Note: patients sensitive to procaine and
procainamide may be sensitive to metoclopramide
• Patients with porphyria
• Metoclopramide should not be used in patients with epilepsy since it may increase the frequency
and severity of seizures
• Metoclopramide should not be administered to patients receiving other drugs which are likely to
cause extrapyramidal reactions, since the frequency and severity of extrapyramidal reactions may
be increased
• Metoclopramide should not be used in children below 1 year of age

4.4 Special warnings and precautions for use

Persistent Tardive Dyskinesia

Tardive dyskinesia may appear in some patients on long-term therapy or may appear after drug therapy
has been discontinued. The risk appears to be greater in elderly patients on high dose therapy, especially
females. The symptoms are persistent and can often at times appear to be irreversible. The syndrome
is characterised by rhythmical involuntary movement of the tongue, face, mouth or jaw (e.g. protrusion

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of tongue, puffing of cheeks, puckering of mouth, chewing movements). Sometimes these may be
accompanied by involuntary movement of extremities. There is no known effective treatment for
tardive dyskinesia; however, in some patients symptoms may lessen or resolve after metoclopramide
treatment is stopped. Antiparkinson agents usually do not alleviate the symptoms of this syndrome.

Although the risk of tardive dyskinesia with metoclopramide has not been extensively studied, one
published study reported a tardive dyskinesia prevalence of 20% among patients treated for at least 3
months. Both the risk of developing the syndrome and the likelihood that it will become irreversible
are believed to increase with the duration of treatment and the total cumulative dose.

Metoclopramide therapy should routinely be discontinued in patients who develop signs or symptoms
of tardive dyskinesia. It has been suggested that fine vermicular movements of the tongue may be an
early sign of the syndrome, and, if the medication is stopped at that time, the syndrome may not develop.
Tardive dyskinesia may remit, partially or completely, within several weeks to months after
metoclopramide is withdrawn. Metoclopramide itself, however, may suppress (or partially suppress)
the signs of tardive dyskinesia thereby masking the underlying disease process. The effect of this
symptomatic suppression upon the long-term course of the syndrome is unknown. Therefore
metoclopramide should not be used for the symptomatic control of tardive dyskinesia.

Prolonged treatment (greater than 12 weeks) with metoclopramide should be avoided in all but rare
cases where the therapeutic benefit is thought to outweigh the risks to the patient of developing tardive
dyskinesia.

Care should be exercised in patients being treated with other centrally active drugs.

Since extrapyramidal symptoms may occur with both metoclopramide and neuroleptics such as
phenothiazines, care should be exercised in the event of both drugs being prescribed concurrently (see
section 4.5). The frequency and severity of seizures or extrapyramidal reactions may be increased in
epileptic patients given metoclopramide.

Dystonic Reactions
Dystonic reactions occur in approximately 1% of patients given metoclopramide. These occur more
often in children and young adults and may occur after a single dose.

Neuroleptic Malignant Syndrome

Neuroleptic malignant syndrome has been reported when metoclopramide has been used alone or in
combination with neuroleptics (see section 4.8).

Prolactin Levels
Metoclopramide elevates prolactin levels and the elevation persists during chronic administration (see
Section 4.8). This may be of importance in patients with previously detected breast cancer, in which
the breast cancer is prolactin dependent. Tissue culture experiments indicate that approximately one-
third of human breast cancers are prolactin dependent in vitro, a factor of potential importance if the
prescription of Metoclopramide is contemplated in a patient with previously detected breast cancer.
Although prolactin elevating drugs have been associated with disturbances such as galactorrhoea,
amenorrhoea, gynaecomastia and impotence, the clinical significance of elevated serum prolactin levels
is not known for most patients. Chronic administration of prolactin stimulating neuroleptic drugs to
rodents has shown an increase in mammary neoplasms. However, neither clinical or epidemiological
studies have shown an association between chronic administration of these drugs and mammary
tumorogenesis in humans and the available evidence is too limited to be conclusive at this time.

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Other
Metoclopramide should be withheld for three to four days following operations such as pyloroplasty or
gut surgery as vigorous muscular contractions may inhibit healing.

Special care should be taken in cases of severe renal insufficiency (see section 4.2).

The effects of metoclopramide may mask symptoms and delay the recognition of a serious disease. It
should not be prescribed until diagnosis has been established, and should not be substituted for
appropriate investigation of the patient's symptoms.

If vomiting persists in a patient being treated with metoclopramide, the patient’s condition should be
re-assessed to exclude the possibility of a more serious underlying disorder such as cerebral irritation.

Metoclopramide Injection should be administered slowly over 1-2 minutes by intravenous injection to
avoid a transient but intense feeling of anxiety and restlessness, followed by drowsiness, which may
occur with rapid administration.

Patients should be cautioned about engaging in activities requiring mental alertness for a few hours after
the drug has been administered.

Metoclopramide induced depression has been reported in patients without a prior history of depression.
Symptoms have ranged from mild to severe and have included suicidal ideation and suicide (see section
4.8). Metoclopramide should be given to patients with a prior history of depression only if the expected
benefits outweigh the potential risks.

Metoclopramide should be used with caution in patients with hypertension as intravenously

administered metoclopramide has been shown to release catecholamines.

Patients receiving prolonged treatment with metoclopramide should be reviewed regularly.

Metoclopramide can exacerbate parkinsonian symptoms; therefore it should be used with caution, if at
all, in patients with parkinsonian syndrome (see section 4.8).

Use in hepatic impairment

In patients with clinically significant degrees of hepatic impairment, clearance of metoclopramide is

likely to be reduced (see section 4.2).

Use in renal impairment

In patients with clinically significant degrees of renal impairment, clearance of metoclopramide is likely
to be reduced. Special care should be taken in cases of severe renal insufficiency (see section 4.2).

Paediatric population

Metoclopramide is contraindicated in children less than 1 year of age. Metoclopramide should not be
given to children unless a clear indication has been established for its use. Children are at a greater risk
of experiencing adverse reactions to metoclopramide.

Use in the Elderly

To avoid adverse reactions adhere strictly to dosage recommendations and where prolonged therapy is
considered necessary, patients should be regularly reviewed.

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Effect on Laboratory Tests
Metoclopramide may blunt the response to the gonadorelin diagnostic test, by increasing serum
prolactin levels. Metoclopramide may alter hepatic function test results.

4.5 Interaction with other medicines and other forms of interaction

Anticholinergic drugs and narcotic analgesics may antagonise the effects of metoclopramide on
gastrointestinal motility.

Alcohol, sedatives, hypnotics, narcotics and tranquilisers have additive sedative effects when
administered in conjunction with metoclopramide.

Due to its effects on gastric motility, metoclopramide may affect the rate of absorption of drugs from
the gastrointestinal tract. Absorption of drugs such as paracetamol, aspirin in patients with migraine,
cyclosporin, diazepam, dopamine, levodopa and morphine controlled release tablets, which are mainly
absorbed from the small bowel, may be accelerated. Absorption of drugs such as digoxin,
bromocriptine, cimetidine, penicillin and quinidine, which are mainly absorbed from the stomach, may
be decreased.

Metoclopramide may cause extrapyramidal symptoms in some patients. Therefore, when

metoclopramide is used concomitantly with other drugs that are likely to cause extrapyramidal
reactions (e.g. neuroleptics such as phenothiazines), caution should be exercised.

The decrease in gastric emptying time caused by metoclopramide may increase the bioavailability of
cyclosporin. Monitoring of cyclosporin concentrations may be necessary.

When metoclopramide is given concurrently with suxamethonium the recovery time is prolonged.

Since metoclopramide influences the delivery of food to the intestine and thus the rate of its absorption,
the administration of metoclopramide may result in poor diabetic control in some patients. Therefore
adjustment in, or timing of, insulin dosage may be necessary in insulin-controlled diabetics.

The finding that metoclopramide releases catecholamines in patients with essential hypertension
suggests that it should be used cautiously, if at all, in patients receiving monoamine oxidase inhibitors.

For compatibility with other medications see sections 4.2 and 6.2.

4.6 Fertility, pregnancy and lactation

Fertility

No Data Available

Pregnancy

Category A
As there are no adequate or well controlled studies in pregnant women, metoclopramide should be used
only if clearly needed. Animal tests in several mammalian species and clinical experience have not
indicated any teratogenic effect. However, metoclopramide is not recommended during the first three
months of pregnancy unless there are compelling reasons to do so.

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Lactation

As metoclopramide is excreted in human breast milk, its use is not recommended in nursing mothers
unless the expected benefit outweighs the potential risk. The increased risk of adverse reactions in
children should be considered when making a risk-benefit assessment.

4.7 Effects on ability to drive and use machinery

Patients should be cautioned about engaging in activities requiring mental alertness for a few hours after
the drug has been administered.

4.8 Undesirable effects

Neurological
The most frequent adverse reactions to metoclopramide are restlessness, drowsiness, fatigue and
lassitude, which occur in approximately 10% of patients.

Less frequently, insomnia, headache, dizziness may occur. Rare (less than 1 in 1,000 cases) of acute
depression have been reported. Symptoms of metoclopramide induced depression have ranged from
mild to severe and have included suicidal ideation and suicide (see section 4.4). Anxiety or agitation
may occur, especially after rapid injection. Delirium, severe dysphoria, obsessive rumination and mania
have been reported occasionally.

Although uncommon at normal dosage, various extrapyramidal reactions to metoclopramide, usually of

the dystonic type, have been reported. Acute dystonic reactions occur in approximately 0.2% of patients
treated with 30 mg to 40 mg of metoclopramide per day. In cancer chemotherapy patients receiving
1 mg/kg to 2 mg/kg per dose, the incidence is 2% in patients over the ages of 30 to 35, and 25% or
higher in children and young adults who have not had prophylactic administration of diphenhydramine.
Reactions include: spasm of the facial muscles, trismus, rhythmic protrusion of the tongue, a bulbar
type of speech, spasm of the extraocular muscles including oculogyric crisis, unnatural positioning of
the head and shoulders and opisthotonos. There may be a generalised increase in muscle tone. The
majority of reactions occur within 36 hours of starting treatment and the effects usually disappear within
24 hours of withdrawal of the drug. However, close observation is required and in cases of more severe
reactions an antiparkinson drug such as benztropine or an anticholinergic antihistamine such as
diphenhydramine should be given.

A fatal dystonic reaction has been reported in a patient who received hexamethylmelamine, cisplatin
and high dose metoclopramide. Dystonic reactions may present rarely as upper airway obstruction with
stridor and dyspnoea, possibly secondary to laryngospasm or supraglottic dystonia. A fatal
cardiorespiratory arrest occurred in at least one patient with an acute dystonic reaction.

Tardive dyskinesia, which may be persistent, has been reported particularly in elderly patients
(particularly women) undergoing long term therapy with metoclopramide. Tardive dyskinesia is most
frequently characterised by involuntary movements of the tongue, face, mouth or jaw, and sometimes
by involuntary movements of the trunk and/or extremities. The risk of developing tardive dyskinesia
and the likelihood that it will become irreversible are believed to increase with increasing duration of
therapy and total cumulative dose. Although tardive dyskinesia can occur after relatively brief therapy
with the drug at low doses, it appears to be more readily reversible under such circumstances (see section
4.4).

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Very rare (less than 1 in 10,000) occurrences of neuroleptic malignant syndrome (NMS) have been
reported. NMS is potentially fatal and comprises hyperpyrexia, altered consciousness, muscle rigidity,
autonomic instability and elevated levels of CPK, and must be treated urgently (recognised treatments
include dantrolene and bromocriptine). Metoclopramide should be stopped immediately if NMS occurs.

Parkinsonian symptoms, including tremor, rigidity, bradykinesia and akinesia, occur rarely in patients
receiving metoclopramide but may be associated with usual or excessive doses or with decreased renal
function.

Gastrointestinal
Less frequently, nausea or bowel disturbances, may occur.

Cardiovascular
A single case of supraventricular tachycardia following intramuscular administration has been reported.
There have been very rare (less than 1 in 10,000) cases of abnormalities of cardiac conduction (such as
bradycardia and heart block) in association with intravenous metoclopramide. Hypertension,
hypotension, cardiac arrest, atrial fibrillation (AF), oedema, ventricular fibrillation, tachycardia,
ventricular tachycardia and palpitations have also been associated with the use of metoclopramide. In
one study in hypertensive patients, intravenously administered metoclopramide was shown to release
catecholamines; hence, caution should be exercised when metoclopramide is used in patients with
hypertension.

Endocrine
Raised serum prolactin levels have been observed during metoclopramide therapy; this effect is similar
to that noted with many other compounds. Galactorrhoea and breast enlargement have also been
observed during metoclopramide therapy.

Hypersensitivity
There have been isolated reports of hypersensitivity reactions (such as urticaria, maculopapular rash) in
patients receiving metoclopramide.

Respiratory
Respiratory failure, secondary to dystonic reaction, acute asthmatic symptoms of wheezing and
dyspnoea may occur.

Genitourinary
Urinary incontinence, sexual dysfunction, priapism and muscle spasm may also occur.

Hepatic Disorders

Rarely, cases of hepatotoxicity, characterised by such findings as jaundice and altered liver function
tests, when metoclopramide was administered with other drugs with known hepatotoxic potential.

Blood Disorders
There have been isolated reports of blood disorders. Methaemoglobinaemia, particularly following
overdose in neonates, has also occurred in patients receiving the drug. Neutropenia, leucopenia and
agranulocytosis has been reported.

Sulfhaemoglobinaemia in adults has been reported.

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General Disorders
Hyperthermia has also been observed.

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation of the medicine is important. It allows
continued monitoring of the benefit/risk balance of the medicine. Healthcare professionals are asked to
report any suspected adverse reactions https://nzphvc.otago.ac.nz/reporting/.

4.9 Overdose

Signs and Symptoms

Limited information is available on the acute toxicity of metoclopramide. Overdosage of
metoclopramide may be expected to produce effects that are extensions of common adverse reactions:
drowsiness, disorientation, and extrapyramidal reactions have been the principal effects reported. Other
reported effects associated with metoclopramide overdosage have included feelings of anxiety or
restlessness, headache, vertigo, nausea, vomiting, constipation, weakness, hypotension, and xerostomia;
in addition generalized seizures and methaemoglobinaemia have occurred in infants. AV block has
been observed very rarely.

Treatment of Overdosage
Treatment of metoclopramide overdose generally involves close observation, symptomatic and
supportive care. There is no specific antidote for metoclopramide intoxication; however, antiparkinson
and antihistamine/anticholinergic drugs (e.g. diphenhydramine, benztropine) have effectively
controlled extrapyramidal reactions. Symptoms of metoclopramide overdose are generally self-limiting
and usually subside within 24 hours. Appropriate therapy should be instituted if hypotension or
excessive sedation occurs. Methaemoglobinaemia should be treated with methylene blue.
Haemodialysis or peritoneal dialysis is unlikely to enhance the elimination of metoclopramide.

For advice on the management of overdose please contact the National Poisons Centre on 0800 POISON
(0800 764766).

5. PHARMACOLOGICAL PROPERTIES
5.1 Pharmacodynamic properties
Class of Drug
Antiemetic.

Mode of Action
Metoclopramide has antiemetic, antinauseant and gastrokinetic activity. It stimulates motility of the
upper gastrointestinal tract without stimulating gastric, biliary or pancreatic secretions. The rate of
gastric emptying is increased due to increased peristalsis of the jejunum and duodenum. The tone and
amplitude of gastric contractions are increased, with relaxation of the pyloric sphincter and duodenal
bulb. These effects combine to result in decreased intestinal transit time. The effect of metoclopramide
on motility is not dependent on intact vagal innervation, but it can be abolished by anticholinergic drugs.
Metoclopramide has little, if any, effect on the motility of the colon or bladder. Metoclopramide also
exhibits dopamine antagonist activity and consequently produces sedation and, rarely, other
extrapyramidal reactions. It may have serotonin receptor (5HT3) antagonist properties.
Metoclopramide inhibits the central and peripheral effects of apomorphine, induces release of prolactin
and produces a transient increase in circulating aldosterone levels.

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5.2 Pharmacokinetic properties Absorption
Following intravenous administration, the onset of action is within 1 to 3 minutes and after
intramuscular administration, this interval is extended to 10 to 15 minutes. The effect usually lasts from
1 to 2 hours.

Distribution
Plasma protein binding is 13% to 22%.

Metabolism
About 80% of the drug is excreted in the urine in the first 24 hours after administration. Approximately
half is unchanged metoclopramide and half is the glucuronide and sulphate conjugate.

Elimination
Metabolism mainly occurs in the liver and elimination half-life may vary from 2.5 to 6 hours. Impaired
renal function results in a reduced clearance and an increased half-life, up to 15 hours.

5.3 Preclinical safety data

Genotoxicity

No Data Available

Carcinogenicity

No Data Available

Reproductive and developmental toxicity

No Data Available

6. PHARMACEUTICAL PARTICUALRS

6.1 List of excipients

Sodium Chloride

Sodium Hydroxide and/or Hydrochloric Acid for pH adjustment

Water for Injections

6.2 Incompatibilities

See section 4.2 (Dose and method of administration – Compatibilities).

If the standard formulation of metoclopramide is used for the treatment of nausea and vomiting
associated with cytotoxic drugs, the cytotoxic agent should be administered as a separate infusion.

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6.3 Shelf life

24 Months.

6.4 Special precautions for storage

Store below 25ºC. Protect from light.

If ampoules are removed from their carton, they should be stored away from light. If inadvertent
exposure occurs, ampoules showing a yellow discolouration must be discarded.

6.5 Nature and contents of container

Metoclopramide Injection 10 mg in 2 mL (sterile) ampoule (10s)

Metoclopramide Injection 10 mg in 2 mL (sterile) ampoule (50s)

6.6 Special precautions for disposal

ANY UNUSED MEDICINE OR WASTE MATERIAL SHOULD BE DISPOSED OF IN

ACCORDANCE WITH LOCAL REQUIREMENTS.

7. MEDICINE SCHEDULE
Prescription Only Medicine

8. SPONSOR
LumaCina New Zealand
C/o Quigg Partners
Level 7, The Bayleys Building
36 Brandon Street,
Wellington 6011, New Zealand
Telephone: 0800 822 634
[email protected]

9. DATE OF FIRST APPROVAL

19 December 1991

10. DATE OF REVISION OF THE TEXT

20 October 2023

Summary table of changes

Section changed Summary of new information

8 Updated Sponsor details

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