[08 July 2013]
Products Affected - Description
Reason for the Shortage
- Baxter had metoclopramide injection on back order due to regulatory issues. Baxter sold some generic injectable products to West-Ward. West-Ward then discontinued the metoclopramide injection in January, 2012.1
- Teva discontinued metoclopramide injection in February, 2011.2
- Hospira discontinued metoclopramide ampules in February, 2010, and Carpuject syringes in May, 2009.
- Hospira had metoclopramide 5 mg/mL 2 mL vials on shortage due to manufacturing delays.3
Metoclopramide injection, Hospira
5 mg/mL, 2 mL vials (NDC 00409-3414-01)
Metoclopramide injection, BD Rx
5 mg/mL, 2 mL prefilled syringes (NDC 76045-0101-20)
Estimated Resupply Dates
- All presentations are currently available.3
Implications for Patient Care
- Metoclopramide is a dopamine agonist antiemetic used to control nausea and vomiting produced by a variety of causes.4 During this shortage use alternative antiemetics. Oral metoclopramide products are effective; however, these routes may not be practical for all patients.
- Metoclopramide injection is also used for a variety of indications to promote gastric emptying.4
Alternative Agents & Management
- No antiemetic is completely effective in preventing nausea and vomiting in all patients. The selection of an antiemetic is often based on the type of nausea and vomiting (eg, chemotherapy-induced, or postoperative) and patient specific criteria.
Chemotherapy Induced Nausea and Vomiting (CINV)
- Treatment guidelines base antiemetic recommendations on the emetogenic potential of the chemotherapy being administered. Treatment guidelines on the management of acute and delayed CINV are available from American Society of Clinical Oncology (ASCO), the National Comprehensive Cancer Network (NCCN), the Antiemetic Subcommittee of the Multinational Association of Supportive Care in Cancer (MASCC), and the European Society for Medical Oncology (ESMO).5-9
- The role of metoclopramide in the management of acute CINV is limited to use for low or minimal emetogenic chemotherapy,5,6 and for refractory or breakthrough nausea and vomiting.9 Table 1 and Table 2 summarize the dose recommendations from the NCCN clinical guidelines.6,9 Alternative dosing regimens may be found in other resources.
Postoperative Nausea and Vomiting (PONV)
- PONV is best managed by prevention, as response to prophylaxis is much higher than response to treatment of established nausea or vomiting. Various medications, working by multiple mechanisms of action, are used to manage PONV.11,12
- Guidelines on the management of postoperative nausea and vomiting are available from the International Anesthesia Research Society (2003), American Society of Anesthesiologists (2002), American Society of PeriAnesthesia Nurses (2006), Society for Ambulatory Anesthesia (2007), and American Society of Plastic Surgeons Task Force and Committee for Patient Safety (2006), and Society for Obstetricians and Gynecologists of Canada (2008).13-18
- The emphasis of these guidelines is to identify adults and children at moderate to high risk for PONV, reduce any baseline risk factors for PONV, and provide prophylaxis with 2 or 3 different types of antiemetic agents. If a patient has nausea and vomiting despite prophylaxis, treat with an antiemetic from a different pharmacological class.13-18
- Antiemetic therapy for PONV prophylaxis or treatment in adults includes: 5-HT3 receptor antagonists, dexamethasone, aprepitant, droperidol, prochlorperazine, promethazine, scopolamine patch, dimenhydrinate, ephedrine, or propofol anesthesia. Most guidelines recommend using a prophylactic antiemetic regimen that contains a 5-HT3 antagonist.13-19 For the treatment of PONV, the 5-HT3 receptor antagonists are the most well-studied agents.11
- Table 3 provides doses for selected agents used for the management of PONV in adults.
- Baxter, Customer Service (personal communication). September 13, 2011; and January 20, 2012.
- Teva, Customer Service (personal communication). February 4, 2011.
- Hospira, Customer Service (personal communication). January 9 and 30, March 5 and 28, May 24, June 11, August 6, September 4, October 24, November 6 and 28, December 17, 2012; January 14 and 28, February 26, March 8, May 20, and June 11, 2013.
- McEvoy GK, Snow EK, Kester L, Litvak K, Miller J, Welsh OH, eds. AHFS 2010 Drug Information. Bethesda, MD: American Society of Health-System Pharmacists; 2008.
- Kris MG, Hesketh PJ, Somerfield MR, et al. American Society of Clinical Oncology guideline for antiemetics in oncology: update 2006. J Clin Oncol. Jun 20 2006;24(18):2932-2947.
- Ettinger DS, Armstrong D, Barbour S, et al. Antiemesis. National Comprehensive Cancer Network, Practice Guidelines in Oncology, v.3.2009. Available on the National Comprehensive Cancer Network website. Accessed August 5, 2009
- Ettinger DS, Bierman PJ, Bradbury B, et al. Antiemesis. J Natl Compr Canc Netw. Jan 2007;5(1):12-33.
- Herrstedt J. Antiemetics: an update and the MASCC guidelines applied in clinical practice. Nat Clin Pract Oncol. Jan 2008;5(1):32-43.
- Herrstedt J, Roila F. Chemotherapy-induced nausea and vomiting: ESMO clinical recommendations for prophylaxis. Ann Oncol. May 2008;19 Suppl 2:ii110-112.
- Hesketh PJ. Chemotherapy-induced nausea and vomiting. N Engl J Med. Jun 5 2008;358(23):2482-2494.
- Golembiewski J, Chernin E, Chopra T. Prevention and treatment of postoperative nausea and vomiting. Am J Health Syst Pharm. Jun 15 2005;62(12):1247-1260; quiz 1261-1242.
- Golembiewski JA, O'Brien D. A systematic approach to the management of postoperative nausea and vomiting. J Perianesth Nurs. Dec 2002;17(6):364-376.
- Gan TJ, Meyer T, Apfel CC, et al. Consensus guidelines for managing postoperative nausea and vomiting. Anesth Analg. Jul 2003;97(1):62-71.
- Practice guidelines for postanesthetic care: a report by the American Society of Anesthesiologists Task Force on Postanesthetic Care. Anesthesiology. Mar 2002;96(3):742-752.
- ASPAN'S evidence-based clinical practice guideline for the prevention and/or management of PONV/PDNV. J Perianesth Nurs. Aug 2006;21(4):230-250.
- Gan TJ, Meyer TA, Apfel CC, et al. Society for Ambulatory Anesthesia guidelines for the management of postoperative nausea and vomiting. Anesth Analg. Dec 2007;105(6):1615-1628, table of contents.
- Iverson RE, Lynch DJ. Practice advisory on pain management and prevention of postoperative nausea and vomiting. Plast Reconstr Surg. Sep 15 2006;118(4):1060-1069.
- McCracken G, Houston P, Lefebvre G. Guideline for the management of postoperative nausea and vomiting. J Obstet Gynaecol Can. Jul 2008;30(7):600-607, 608-616.
- Ignoffo RJ. Current research on PONV/PDNV: Practical implications for today's pharmacist. Am J Health Syst Pharm. Jan 1 2009;66(1 Suppl 1):S19-24.
- Donnelly AJ, Baughman VL, Gonzales JP, Golembiewski J, Tomsik EA, eds. Anesthesiology and Critical Care Drug Handbook. 8th ed. Hudson, OH: Lexi-Comp; 2008.
- Aloxi (palonosetron hydrochloride) capsules package insert. Bloomington, MN: Eisai Inc.; August 2008.
Updated July 8, 2013 by Kristen Jefferies, PharmD, Drug Information Specialist; January 28, 2013 by Jane Chandramouli, PharmD, Drug Information Specialist. Created August 6, 2009, by Jane Chandramouli, PharmD, Drug Information Specialist. Copyright 2013, Drug Information Service, University of Utah, Salt Lake City, UT.
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