METOZOLV ODT(metoclopramide hydrochloride) Orally Disintegrating Tablets（盐酸甲氧氯普胺口服崩解片） Salix 制药公司在2009年9月8日宣布：5mg 和 10mg Metozolv ODT（盐酸甲氧氯普胺口服崩解片）已获美国食品药品管理局（FDA）的上市批准。Metozolv ODT获批用于成年患者急性和复发性糖尿病胃轻瘫相关症状的治疗。该药物还可用于常规治疗无效的有症状的胃食管反流病（GERD）成年患者的短期治疗（4～12周）。 甲氧氯普胺是一种强效多巴胺受体拮抗剂，具有促进胃排空和止吐的功效，自1980年起就开始在美国使用。在Metozolv ODT获批之前，甲氧氯普胺有静注、肌注和口服片剂配方。 Metozolv ODT禁用于肠梗阻、出血、穿孔、嗜铬细胞瘤、癫痫或正在接受锥体外系反应相关合并用药的患者。抗精神病药恶性综合征（NMS）、高血压、充血性心力衰竭、室性心律失常和有抑郁症病史的患者以及表现有急性弛缓性反应、药源性帕金森综合征或其他锥体外系症状的患者应慎用此药。患者停用Metozolv ODT后可能会出现戒断症状。 临床上应用甲氧氯普胺可引起迟发性运动障碍，这是一种严重的运动失调，往往不可逆。迟发性运动障碍的发生风险随治疗持续时间和总累积剂量的增加而增加。应尽量避免使用甲氧氯普胺超过12周，除了极少数治疗获益超过迟发性运动障碍发生风险的患者。 部分中文METOZOLV ODT处方资料（仅供参考） METOZOLV的ODT 制造商： 柳制药公司 类药物： 促动力/ antidopaminergic 活性成分（S）： 胃复安（盐酸）5毫克，10毫克，口服崩解选项卡;薄荷味。 指示（S）： 短期（4-12周）治疗症状的难治性GERD的。为了减轻急性和经常性糖尿病性胃轻瘫的症状。 药理： 胃复安是一种有效的多巴胺受体拮抗剂，促进胃排空及止吐的功能。胃排空延迟发生时迷走神经受损，导致乙酰胆碱分泌受损和失去正常的胃和肠道的肌肉收缩。胃复安敏感组织对乙酰胆碱的刺激上消化道的蠕动，无刺激胃，胆道，胰腺分泌物。它增加胃收缩的基调和幅度，松弛幽门括约肌和十二指肠球部，并增加，以加速胃排空和肠转运十二指肠和空肠的蠕动。胃复安也增加了GERD的管理降低食管括约肌静息音。 胃复安发挥其通过拮抗中枢和外周多巴胺受体的止吐效果。多巴胺产生刺激延髓化学感受器触发区（CTZ），恶心和呕吐。左旋多巴或阿朴吗啡剂，这是众所周知的增加多巴胺的水平，或拥有类似多巴胺的影响的刺激CTZ胃复安块。 Metozolv ODT是口腔崩解片剂盐酸胃复安。应采取空腹进食前至少30分钟，因为食物可以减少峰浓度的药物和/或花费的时间达到最大血液中的药物水平。若不慎与食物一起服用超过4的过程中偶尔 - 至12周的疗程，这种下降是没有临床意义。 法律分类： 接收 成人： 允许片剂溶于舌。胃食管反流：10 15毫克每天4次，饭前30分钟，并在睡前。间歇性症状：以20mg之前，发人深省的情况;最大每疗程12周。糖尿病胃轻瘫：每天10毫克的4倍30分钟饭前和睡前2-8周。肾损害：减少剂量。 儿童： 不推荐。 禁忌（S）： 当胃肠道蠕动的刺激可能是危险的（例如，梗阻，穿孔或出血）。嗜铬细胞瘤。癫痫。伴随药物，这可能会导致锥体外系反应（例如，抗抑郁药，抗精神病药物，抗精神病药）。 警告/注意事项： 停止迟发性运动障碍的症状/体征的发展;与治疗的持续时间和总累积剂量的危险性增加。帕金森病。抑郁症的历史。高血压。瑞士法郎。心律失常。老人。怀孕（Cat.B）。哺乳的母亲。 相互作用（S）： 与单胺氧化抑制剂的高血压危象。添加剂镇静用酒精，其他中枢神经系统抑制剂。拮抗抗胆碱能药物和毒品。监视器使用胰岛素，可能会减少的胃和加快肠道吸收的药物或食物。 不良反应（S）： 头痛，恶心，呕吐，乏力，嗜睡，头晕，锥体外系的影响，帕金森病，迟发性运动障碍，抗精神病药恶性综合征，高血压。 如何提供： 标签10 × 10（泡罩包装） 最后更新： 2/2/2010 【原产地英文商品名】METOZOLV ODT 5mg/tablet 100tablets/box 【原产地英文药品名】(metoclopramide hydrochloride) Orally Disintegrating Tablets 【中文参考商品译名】 注：以下产品不同规格和不同价格，购买时请以电话咨询为准！ ·METOZOLV ODT 10毫克/片 100片/盒 ·METOZOLV ODT 5毫克/片 100片/盒 【中文参考药品译名】盐酸甲氧氯普胺口服崩解片 【生产厂家中文参考译名】SALIX PHARMS 【生产厂家英文名】SALIX PHARMS METOZOLV ODT (metoclopramide hydrochloride) Orally Disintegrating Tablets DRUG DESCRIPTION METOZOLV ODT is an orally disintegrating tablet formulation of metoclopramide hydrochloride. The 5 mg strength is a round white tablet debossed on one side with a “5” and plain on the other side; it is comprised of 5 mg metoclopramide (as 5.91 mg of metoclopramide hydrochloride ) with gelatin, mannitol, mint flavoring, and Acesulfame K (artificial sweetener). The 10 mg strength is a round white tablet debossed on one side with a “ 10” and plain on the other side; it is comprised of 10 mg metoclopramide (as 11.82 mg of metoclopramide hydrochloride) with gelatin, mannitol, mint flavoring, and Acesulfame K. The active ingredient, metoclopramide hydrochloride, is a white crystalline, odorless substance, freely soluble in water. Chemically, it is 4-amino-5-chloro-N-[2-(diethylamino)ethyl]-2-methoxy benzamide monohydrochloride monohydrate. Its molecular formula is C14H22ClN3O2•HCl•H2O. Its molecular weight is 354.3. METOZOLV ODT includes the following inactive ingredients: gelatin, mannitol, mint flavoring, Acesulfame Potassium (artificial sweetener), and trace amounts of sodium chloride and sodium hydroxide. ----------------------------------------------------------------- INDICATIONS Symptomatic Gastroesophageal Reflux Disease METOZOLV ODT is indicated as short-term (4 to 12 weeks) therapy for adults with symptomatic, documented gastroesophageal reflux disease (GERD) who fail to respond to conventional therapy. Diabetic Gastroparesis (Diabetic Gastric Stasis) METOZOLV ODT is indicated for the relief of symptoms associated with acute and recurrent diabetic gastroparesis (gastric stasis) in adults. Important Limitations METOZOLV ODT is indicated for adults only. Therapy should not exceed 12 weeks in duration. The safety and effectiveness in pediatric patients have not been established. ----------------------------------------------------------------- DOSAGE AND ADMINISTRATION Important Instructions for Use Take on an empty stomach at least 30 minutes before eating since food can decrease the peak concentrations of drug in the bloodstream and/or the time it takes to achieve the maximum drug level in the bloodstream [see CLINICAL PHARMACOLOGY]. Do not repeat dose if inadvertently taken with food. Since the tablet absorbs moisture rapidly, only remove each dose from the packaging just prior to taking. Handle the tablet with dry hands and place on the tongue. If the tablet should break or crumble while handling, discard and remove a new tablet. Metozolv ODT disintegrates on the tongue in approximately one minute (with a range of 10 seconds to 14 minutes). METOZOLV ODT is designed to be taken without liquid; however, the effect on the pharmacokinetics of taking METOZOLV ODT with liquid is unknown. Symptomatic Gastroesophageal Reflux Disease For the relief of symptomatic, documented gastroesophageal reflux disease (GERD), therapy should not exceed 12 weeks in duration. Take 10 mg to 15 mg dose of METOZOLV ODT up to four times daily (e.g., at least 30 minutes before each meal and at bedtime). Doses may vary depending upon the symptoms being treated and the clinical response. If symptoms only occur intermittently or at specific times of the day, metoclopramide may be used in single doses up to 20 mg prior to the symptoms rather than continuous treatment. Since there is a poor correlation between symptomatic relief and healing of esophageal lesions, any therapy directed at esophageal lesions is best confirmed by endoscopic evaluation. Although experience with the effects of metoclopramide on esophageal erosions and ulcerations is limited, healing was documented in a controlled trial using four times daily therapy at 15 mg/dose. Prolonged treatment ( > 12 weeks) with metoclopramide should be avoided in all but rare cases where therapeutic benefit is thought to counterbalance the risks to the patient of developing tardive dyskinesia. [see WARNINGS AND PRECAUTIONS] Diabetic Gastroparesis (Diabetic Gastric Stasis) For the relief of symptoms associated with diabetic gastroparesis (diabetic gastric stasis), therapy of two to eight weeks is recommended. Therapy should not exceed 12 weeks in duration. Take a 10 mg dose of METOZOLV ODT up to four times a day (e.g., at least 30 minutes before each meal and at bedtime). The initial route of administration should be determined by the severity of the presenting symptoms. If only the earliest manifestations of diabetic gastric stasis are present, oral administration of METOZOLV ODT may be initiated. However, if severe symptoms are present, therapy should begin with metoclopramide injection. Administration of metoclopramide injection up to 10 days may be required before symptoms subside, at which time oral administration may be instituted. Since diabetic gastric stasis is frequently recurrent, METOZOLV ODT therapy should be reinstituted at the earliest manifestation. Renal Impairment Some patients, such as the elderly or those with impaired kidney function (creatinine clearance below 40 mL/min) may be more sensitive to the therapeutic dose or the adverse effects of metoclopramide. Therefore, these patients should start therapy at a lower dose (approximately half the recommended dosage) and the dose should be titrated according to their overall clinical response and/or adverse event profile. Dialysis is not likely to be an effective method of drug removal in overdose situations. ----------------------------------------------------------------- HOW SUPPLIED Dosage Forms And Strengths 5 mg Tablets: Each white round 5 mg tablet is debossed with “5” on one side and plain on the other. 10 mg Tablets: Each white round 10 mg tablet is debossed with “10” on one side and plain on the other. 5 mg Tablets: Available in blister pack with 10 tablets individually sealed in a foil-backed unit-dose container; a carton contains 10 cards (NDC 65649-431-02). 10 mg Tablets: Available in blister pack with 10 tablets individually sealed in a foil-backed unit-dose container; a carton contains 10 cards (NDC 65649-432-02). Tablets should be stored at controlled room temperature, between 20°C and 25°C (68°F and 77°F). ----------------------------------------------------------------- SIDE EFFECTS Clinical Trials Experience Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical studies of another drug and may not reflect the rates observed in clinical practice. A total of 86 subjects entered three studies with METOZOLV ODT; 12 subjects entered a pilot bioavailability study (BA); 44 subjects entered a bioequivalence (BE) study, and 30 subjects entered a food-effect study. The adverse reactions from the BE and food-effect study are summarized in Table 1. The pilot BA study data are not included because it was performed with a formulation different from the METOZOLV ODT formulation. The adverse experience profile seen with METOZOLV ODT was similar to metoclopramide tablets. Thirty-three (33) adverse reactions were reported after receiving METOZOLV ODT and 30 adverse reactions were reported after receiving metoclopramide tablets. The most frequently reported adverse reactions (greater than 2%) associated with METOZOLV ODT were: nausea, vomiting, fatigue, somnolence and headache. The most frequently reported adverse reactions (greater than 2%) associated with metoclopramide tablets were: nausea, headache, fatigue, somnolence, and dizziness. The combined data from the fasted BE study and the food-effect study did not demonstrate any significant differences in the adverse event profile for METOZOLV ODT compared to metoclopramide tablets. Post-Marketing Experience The following adverse reactions are from the cumulative post-marketing experience with metoclopramide tablets. Since the reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. CNS Effects: Restlessness, drowsiness, fatigue, and lassitude occur in approximately 10% of patients receiving the most commonly prescribed dosage of 10 mg four times a day. Insomnia, headache, confusion, dizziness, or depression with suicidal ideation occurs less frequently. The incidence of drowsiness is greater at higher doses. There are isolated reports of seizures without clear-cut relationship to metoclopramide. Rarely, hallucinations have been reported. Extrapyramidal Syndromes (EPS): Acute dystonic reactions, the most common type of EPS associated with metoclopramide, occur in approximately 0.2% of patients (1 in 500) treated with 30 to 40 mg of metoclopramide per day. Symptoms include involuntary movements of limbs, facial grimacing, torticollis, oculogyric crisis, rhythmic protrusion of tongue, bulbar type of speech, trismus, opisthotonus (tetanus-like reactions), and rarely, stridor and dyspnea possibly due to laryngospasm; ordinarily these symptoms are readily reversed by diphenhydramine ([see WARNINGS AND PRECAUTIONS]. Drug-induced parkinsonian-like symptoms may include bradykinesia, tremor, cogwheel rigidity, mask-like facies [see WARNINGS AND PRECAUTIONS]. Tardive dyskinesia is most frequently characterized by involuntary movements of the tongue, face, mouth, or jaw, and sometimes by involuntary movements of the trunk and/or extremities; movements may be choreoathetotic in appearance. Motor restlessness (akathisia) may include inability to sit still, pacing, and foot tapping. These symptoms may disappear spontaneously or respond to a reduction in dosage. Neuroleptic Malignant Syndrome: Rare occurrences of Neuroleptic Malignant Syndrome (NMS) have been reported [see WARNINGS AND PRECAUTIONS]. Endocrine Disturbances: Galactorrhea, amenorrhea, gynecomastia, and impotence secondary to hyperprolactinemia. Fluid retention secondary to transient elevation of aldosterone. Cardiovascular: Hypotension, hypertension, supraventricular tachycardia, bradycardia, fluid retention, acute congestive heart failure, possible AV block. Gastrointestinal: Nausea, bowel disturbances, primarily diarrhea. Hepatic: Rarely, cases of hepatotoxicity characterized by such findings as jaundice and altered liver function tests, when metoclopramide was administered with other drugs with known hepatotoxic potential. Renal: Urinary frequency and incontinence. Hematologic: A few cases of neutropenia, leukopenia, or agranulocytosis, generally without clear-cut relationship to metoclopramide. Methemoglobinemia in adults and especially with overdosage in neonates. Sulfhemoglobinemia in adults. Allergic Reactions: A few cases of rash, urticaria, or bronchospasm, especially in patients with a history of asthma. Rarely, angioneurotic edema, including glossal or laryngeal edema. Miscellaneous: Visual disturbances. Porphyria. ----------------------------------------------------------------- DRUG INTERACTIONS The effects of metoclopramide on gastrointestinal motility can impact the absorption of other drugs. The known drug-drug interactions are listed below. Anticholinergic and Narcotic Analgesic Drugs The effects of metoclopramide on gastrointestinal motility are antagonized by anticholinergic drugs and narcotic analgesics. Additive sedative effects can occur when metoclopramide is given with alcohol, sedatives, hypnotics, narcotics, or tranquilizers. Monoamine Oxidase Inhibitors Metoclopramide has been shown to release catecholamines in patients with essential hypertension suggests that it should be used cautiously, if at all, in patients taking monoamine oxidase (MAO) inhibitors. Drug absorption Absorption of drugs from the stomach may be diminished by metoclopramide (e.g., digoxin), whereas the rate and/or extent of absorption of drugs from the small bowel may be increased (e.g., acetaminophen, tetracycline, levodopa, ethanol, cyclosporine). Insulin Because the action of metoclopramide will hasten the movement of food to the intestines and therefore the rate of absorption, insulin dosage or timing of dosage may require adjustment. Increasing movement of food to the intestines may lead to absorption of less glucose from a meal, hence less glucose in the circulation for a particular dose of administered insulin to act upon, resulting in hypoglycemia. Antidepressants, antipsychotics, and neuroleptics Concomitant use of metoclopramide should be avoided in patients taking antidepressants, antipsychotics, and/or neuroleptics that have been associated with extrapyramidal reactions such as tardive dyskinesia or Neuroleptic Malignant Syndrome (NMS) that have occurred in association with metoclopramide [see WARNINGS AND PRECAUTIONS and ADVERSE REACTIONS]. ----------------------------------------------------------------- WARNINGS Included as part of the PRECAUTIONS section. ----------------------------------------------------------------- PRECAUTIONS Tardive Dyskinesia Treatment with metoclopramide can cause tardive dyskinesia (TD) [see Boxed Warning], a potentially irreversible and disfiguring disorder characterized by involuntary movements of the face, tongue, or extremities. Although the risk of TD with metoclopramide has not been extensively studied, one published study reported a TD prevalence of 20% among patients treated for at least 12 weeks. Treatment with metoclopramide for longer than 12 weeks should be avoided in all but rare cases where therapeutic benefit is thought to outweigh the risk of developing TD. Although the risk of developing TD in the general population may be increased among the elderly, women, and diabetics, it is not possible to predict which patients will develop metoclopramide-induced TD. Both the risk of developing TD and the likelihood that TD will become irreversible increase with duration of treatment and total cumulative dose. Metoclopramide should be discontinued in patients who develop signs or symptoms of TD. There is no known effective treatment for established cases of TD, although in some patients, TD may remit, partially or completely, within several weeks to months after metoclopramide is withdrawn. Metoclopramide itself may suppress, or partially suppress, the signs of TD, thereby masking the underlying disease process. The effect of this symptomatic suppression upon the long-term course of TD is unknown. Therefore, metoclopramide should not be used for the symptomatic control of TD. Acute Dystonic Reactions, Drug-induced Parkinsonism, and Other Extrapyramidal Symptoms Extrapyramidal symptoms (EPS), manifested primarily as acute dystonic reactions, occur in approximately 1 in 500 patients treated with the usual adult dosages of 30 to 40 mg/day of metoclopramide. These usually are seen during the first 24 to 48 hours of treatment with metoclopramide, occur more frequently in pediatric patients and adult patients less than 30 years of age and are even more frequent at higher doses. These symptoms may include involuntary movements of limbs and facial grimacing, torticollis, oculogyric crisis, rhythmic protrusion of tongue, bulbar type of speech, trismus, or dystonic reactions resembling tetanus. Rarely, dystonic reactions may present as stridor and dyspnea, possibly due to laryngospasm. If these symptoms occur, inject 50 mg diphenhydramine hydrochloride intramuscularly. Benztropine mesylate, 1 to 2 mg intramuscularly, may also be used to reverse these reactions. Drug-induced Parkinsonism can occur during metoclopramide therapy, more commonly within the first 6 months after beginning treatment, but also after longer periods. Parkinsonian symptoms generally subside within 2 to 3 months following discontinuation of metoclopramide. Patients with a history of Parkinson's disease should be given metoclopramide cautiously, if at all, since such patients can experience exacerbation of Parkinsonian symptoms when taking metoclopramide. Neuroleptic Malignant Syndrome There have been rare reports of an uncommon but potentially fatal symptom complex sometimes referred to as Neuroleptic Malignant Syndrome (NMS) associated with metoclopramide. Clinical manifestations of NMS include hyperthermia, muscle rigidity, altered consciousness, and evidence of autonomic instability (irregular pulse or blood pressure, tachycardia, diaphoresis and cardiac arrhythmias). The diagnostic evaluation of patients with this syndrome is complicated. In arriving at a diagnosis, it is important to identify cases where the clinical presentation includes both serious medical illness (e.g., pneumonia, systemic infection) and untreated or inadequately treated extrapyramidal signs and symptoms (EPS). Other important considerations in the differential diagnosis include central anticholinergic toxicity, heat stroke, malignant hyperthermia, drug fever and primary central nervous system (CNS) pathology. The management of NMS should include immediate discontinuation of metoclopramide and other drugs not essential to concurrent therapy; intensive symptomatic treatment and medical monitoring; and, treatment of any concomitant serious medical problems for which specific treatments are available. Bromocriptine and dantrolene sodium have been used in treatment of NMS, but their effectiveness has not been established [see ADVERSE REACTIONS]. Depression Depression associated with metoclopramide use has occurred in patients with and without a history of depression. Symptoms ranged from mild to severe and included suicidal ideation and suicide. For those patients with a prior history of depression, metoclopramide should only be given if the expected benefits outweigh the potential risks. Hypertension 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. There are also clinical reports of hypertensive crises in some patients with undiagnosed pheochromocytoma, thus any rapid rise in blood pressure associated with METOZOLV ODT use should result in immediate cessation of metoclopramide use in those patients [see CONTRAINDICATIONS]. Congestive Heart Failure and Ventricular Arrhythmia Since metoclopramide produces a transient increase in plasma aldosterone, patients with cirrhosis or congestive heart failure may be at risk of developing fluid retention and volume overload. If these side effects occur at any time in any patients during metoclopramide therapy, the drug should be discontinued. Withdrawal from Metoclopramide Adverse reactions, especially those involving the nervous system, may occur after stopping the use of METOZOLV ODT. A small number of patients may experience withdrawal symptoms after stopping that could include dizziness, nervousness, and/or headaches. Patient Counseling Information •Instruct patients to take Metozolv ODT at least 30 minutes before eating and at bedtime. •A patient Medication Guide is available for METOZOLV ODT and printed at the end of the prescribing information. Instruct patients, families, and caregivers to read the Medication Guide and assist them in understanding its contents. •Inform patients or their caregivers of serious potential issues associated with metoclopramide use such as tardive dyskinesia, extrapyramidal symptoms, and neuroleptic malignant syndrome. Advise patients to inform their physician if symptoms associated with these disorders occur during or after treatment with METOZOLV ODT. •Inform patients that METOZOLV ODT may cause drowsiness, dizziness, or otherwise impair mental alertness or physical abilities required for the performance of hazardous tasks such as operating machinery or driving a motor vehicle. Sedation may be more pronounced in the elderly. •Inform patients that the most common adverse reactions in patients treated with METOZOLV ODT or other metoclopramide-containing products are headache, nausea, vomiting, tiredness, sleepiness, dizziness, and restlessness. Nonclinical Toxicology Carcinogenesis, Mutagenesis, Impairment of Fertility A 77-week study was conducted in rats with oral doses up to 40 mg/kg/day (about 5 times the maximum recommended human dose on surface area basis). Metoclopramide elevates prolactin levels and the elevation persists during chronic administration. 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 disturbances such as galactorrhea, amenorrhea, gynecomastia, and impotence have been reported with prolactin-elevating drugs, the clinical significance of elevated serum prolactin levels is unknown for most patients. An increase in mammary neoplasms has been found in rodents after chronic administration of prolactin-stimulating neuroleptic drugs and metoclopramide. Neither clinical studies nor epidemiologic studies conducted to date, however, have shown an association between chronic administration of these drugs and mammary tumorigenesis; the available evidence is too limited to be conclusive at this time. In a rat model for assessing the tumor promotion potential, a two-week oral treatment with metoclopramide at a dose of 260 mg/kg/day (about 35 times the maximum recommended human dose based on body surface area) enhanced the tumorigenic effect of N-nitrosodiethylamine. Metoclopramide was positive in the in vitro Chinese hamster lung cell /HGPRT forward mutation assay for mutagenic effects and the in vitro human lymphocyte chromosome aberration assay for clastogenic effects. It was negative in the in vitro Ames mutation assay, the in vitro unscheduled DNA synthesis (UDS) assay with rat and human hepatocytes and the in vivo rat micronucleus assay. Metoclopramide at intramuscular doses up to 20 mg/kg/day (about 3 times the maximum recommended human dose based on body surface area) was found to have no effect on fertility and reproductive performance of male and female rats. Use In Specific Populations Pregnancy Teratogenic effects: Pregnancy Category B Reproduction studies have been performed in rats at oral doses about 6 times the maximum recommended human dose calculated on the basis of surface area, and in rabbits at oral doses about 12 times the maximum recommended human dose calculated on the basis of surface area, and have revealed no evidence of impaired fertility or harm to the fetus due to metoclopramide. There are, however, no adequate and well-controlled studies in pregnant women. Because animal reproduction studies are not always predictive of human response, this drug should be used during pregnancy only if clearly needed. Labor and Delivery The use of metoclopramide in labor and delivery has not been studied. Nursing Mothers Metoclopramide is excreted in human milk. Caution should be exercised when metoclopramide is administered to a nursing mother. Because of the potential for serious adverse reactions from metoclopramide in nursing infants and because of the potential for tumorigenicity (including tumor promoting potential in rats), a decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother. Pediatric Use The safety and effectiveness of METOZOLV ODT in pediatric patients have not been established. The safety profile of METOZOLV ODT in adults cannot be extrapolated to pediatric patients. Dystonias and other extrapyramidal reactions associated with metoclopramide are more common in the pediatric population than in adults. In addition, neonates have reduced levels of NADH-cytochrome b5 reductase making them more susceptible to methemoglobinemia, a possible side effect of metoclopramide use in neonates. Pediatric PK The pharmacodynamics of metoclopramide following oral and intravenous administration in pediatric populations are highly variable and a concentration-effect relationship has not been established. Thus, there are insufficient data to conclude whether the pharmacokinetics of Metozolv ODT in adults and the pediatric population are similar. Although there are insufficient data to support the efficacy of metoclopramide in pediatric patients with symptomatic gastroesophageal reflux disease (GERD) or cancer chemotherapy-related nausea and vomiting, the pharmacokinetics of metoclopramide have been studied in these patient populations and are summarized as follows. In an open-label study, six pediatric patients (ranging in age from 3.5 weeks to 5.4 months) with GERD received metoclopramide 0.15 mg/kg oral solution every 6 hours for 10 doses. The mean peak plasma concentration of metoclopramide after the tenth dose was twice the level (56.8 mcg/L) compared to after the first dose (29 mcg/L) indicating drug accumulation with repeated dosing. However, the PK parameters after the tenth dose were comparable to those observed after the first dose for the mean time to reach peak concentrations (2.2 hr); half-life (4.1 hr); clearance (0.67 L/h/kg); and volume of distribution (4.4 L/kg). The youngest patient (3.5 weeks) showed a significantly longer half-life after the first dose (23.1 hr) compared to after the tenth dose (10.3 hr), suggesting the reduced clearance observed at birth may be a reflection of the immature hepatic and renal systems. Geriatric Use Clinical studies of metoclopramide did not include sufficient numbers of subjects aged 65 and over to determine whether elderly subjects respond differently from younger subjects. The risk of developing drug-induced parkinsonism due to metoclopramide is dose-related. Geriatric patients should receive the lowest dose that is effective. If drug-induced parkinsonism symptoms develop in a geriatric patient, METOZOLV ODT should be discontinued. The elderly may be at greater risk for tardive dyskinesia [see WARNINGS AND PRECAUTIONS]. Sedation is a potential adverse event associated with metoclopramide use in the elderly. Metoclopramide is known to be substantially excreted by the kidney, and the risk of toxic reactions to this drug may be greater in patients with impaired renal function. For these reasons, dose selection for an elderly patient should be cautious, starting at the low end of the dosing range, due to the greater frequency of decreased renal function, concomitant disease, or other drug therapy in the elderly. [see WARNINGS AND PRECAUTIONS]. Other Special Populations Patients with NADH-cytochrome b5 reductase deficiency are at an increased risk of developing methemoglobinemia and/or sulfhemoglobinemia when metoclopramide is administered. In patients with G6PD deficiency who experience metoclopramide-induced methemoglobinemia, methylene blue treatment is not recommended. Since metoclopramide is excreted principally through the kidneys, therapy should be initiated at approximately one-half the recommended dose in those patients whose creatinine clearance is below 40 mL/min. Depending upon clinical efficacy and safety considerations, the dosage may be increased or decreased as appropriate. Metoclopramide has been safely used in patients with advanced liver disease whose renal function was normal ----------------------------------------------------------------- OVERDOSE Symptoms of overdosage may include drowsiness, disorientation, and extrapyramidal reactions. Anticholinergic or anti-Parkinson drugs or antihistamines with anti-cholinergic properties may be helpful in controlling the extrapyramidal reactions. Symptoms are self-limiting and may disappear within 24 hours. Hemodialysis removes relatively little metoclopramide, probably because of the small amount of the drug in blood relative to tissues. Similarly, continuous ambulatory peritoneal dialysis does not remove significant amounts of drug. It is unlikely that dosage would need to be adjusted to compensate for losses through dialysis. Dialysis is not likely to be an effective method of drug removal in overdose situations. Unintentional overdose has been reported in infants and children with the use of metoclopramide oral solution. While there was no consistent pattern to the reports associated with these overdoses, events included seizures, extrapyramidal reactions, and lethargy. Methemoglobinemia has occurred in premature and full-term neonates who were given overdoses of metoclopramide (1 to 4 mg/kg/day orally, intramuscularly or intravenously for 1 to 3 or more days). Methemoglobinemia can be reversed by the intravenous administration of methylene blue. However, methylene blue may cause hemolytic anemia in patients with G6PD deficiency, which may be fatal. ----------------------------------------------------------------- CONTRAINDICATIONS Intestinal Obstruction, Hemorrhage, or Perforation Do not use Metoclopramide whenever stimulation of gastrointestinal motility may be dangerous such as in the presence of gastrointestinal hemorrhage, mechanical obstruction, or perforation. Pheochromocytoma Metoclopramide is contraindicated in patients with pheochromocytoma because the drug may precipitate a hypertensive crisis, most likely due to release of catecholamines from the tumor. Such hypertensive crises may be controlled by phentolamine. Known Sensitivity or Intolerance Metoclopramide is contraindicated in patients with known sensitivity or intolerance to the drug. Epilepsy Do not use Metoclopramide in patients with epilepsy since the frequency and severity of seizures may be increased. Concomitant Medications with Extrapyramidal Reactions Do not use Metoclopramide in patients receiving other drugs which are likely to cause extrapyramidal reactions, since the frequency and severity of extrapyramidal reactions may be increased [see WARNINGS AND PRECAUTIONS, ADVERSE REACTIONS and DRUG INTERACTIONS].