Prokinetics improve gastrointestinal motility. We advise on suitable prokinetic options, including dose and safety considerations.

Treatment options

Treatment to improve gastrointestinal motility include both non-pharmacological and pharmacological options.

Non-pharmacological options

Non-pharmacological options are usually tried before prokinetic agents. Dietary modification should be tried first line ensuring the person’s diet is low in fat and non-digestible fibre.

Advise the person to avoid spicy and acidic foods, as well as carbonated drinks. Switching to liquid or small particle diets, such as broths and mashed foods, can also improve symptoms.

Prokinetic options

If non-pharmacological options do not relieve symptoms, consider using a prokinetic medicine.

No medicines are licensed as prokinetics in the UK.

First-line prokinetic medicines are metoclopramide and domperidone. Metoclopramide is approved in the United States for diabetic gastroparesis. Domperidone is approved in Canada for gastrointestinal motility disorders associated with gastritis and diabetic gastroparesis.

Erythromycin is a second-line option.

Other options include prucalopride and cisapride (discontinued in the UK).

Clinical considerations

When choosing a prokinetic agent, check the contra-indications, precautions, side effects and interactions listed for the licensed indications as these will still apply. These can be found in the product’s Summary of Product Characteristics.

Metoclopramide

Metoclopramide is a dopamine-2 antagonist that is a first-line treatment option for reduced gastric motility.

Oral dose

The US Food and Drug Administration (FDA) advises an oral dose of 10mg metoclopramide up to 4 times a day for reduced gastric motility. It is given 15-30 minutes before meals and at bedtime.

Intravenous dose

For severe symptoms or when medicines cannot be given orally, the FDA advises an intravenous (IV) dose of 10mg metoclopramide up to 4 times a day for a maximum of 10 days. The dose should be given as per your local IV policy.

Duration of therapy

Oral metoclopramide is usually given for 2 to 8 weeks depending on how well symptoms are being controlled. The maximum recommended duration of treatment is 12 weeks due to the risk of extrapyramidal side effects such as tremor, muscle spasms and involuntary facial movements.

IV metoclopramide is usually given up to a maximum of 10 days.

Safety considerations

There is a risk of extrapyramidal side effects when metoclopramide is used long-term, particularly in children and young adults. Monitor the person for extrapyramidal side effects.

Monitor blood pressure if giving IV due to the risk of hypertension.

Domperidone

Domperidone is a dopamine-2 antagonist that is a first-line treatment option for reduced gastric motility.

Dose

Health Canada advise an oral dose of 10mg domperidone 3 times a day. The dose should be taken 15 to 30 minutes before meals.

Duration of therapy

The MHRA restrict use to a maximum of 7 day duration due to the risk of QT prolongation. However, the use of domperidone for longer than 7 days can be considered if the benefits of therapy outweigh the risk of cardiac effects.

Safety considerations

There is an increased risk of severe cardiac side effects. Risk factors include high dosage (more than 30mg daily) and age over 60 years. Consider taking a baseline ECG and monitoring periodically when used long-term if the patient has risk factors for QT prolongation. Further information can be found on the SPS page for Identifying risk factors for developing a long QT interval.

Erythromycin

When metoclopramide and domperidone are not suitable for prescribing, erythromycin can be used as a second-line option.

Oral dose

The standard dose of oral erythromycin is 250 to 500mg 3 times a day taken before meals.

The maximum dose is 500mg 4 times a day taken before meals and at bedtime.

Erythromycin can also be started at a lower dose of 50 to 100mg 4 times a day and titrated to effect. Starting at a lower dose reduces the risk of tachyphylaxis, which is a sudden decrease in efficacy and loss of symptom control.

Intravenous dose

Erythromycin can also be administered IV if the person’s symptoms are severe or they are nil-by-mouth. The usual IV dose is 3mg/Kg 3 times a day.

Duration of therapy

The recommended maximum duration of therapy is 4 weeks for both oral and IV routes. Longer use is associated with tachyphylaxis.

Safety considerations

IV erythromycin can cause QT prolongation. Monitor ECG if given IV, particularly in those at greater risk of cardiac events. Further information can be found on the SPS page for Identifying risk factors for developing a long QT interval.

IV erythromycin can cause tachycardia and hypotension.

Periodically monitor kidney and liver function if used long-term. If given IV, monitor these on a weekly basis.

Guidelines

The following guidelines discuss the treatment of impaired gastrointestinal motility, including treatment algorithms:

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