Table 1: Alternative Prokinetic Agents
Drug and Usual
Adult Dose 		Mechanism of Action Adverse Effects Comments

Metoclopramide
(Reglan®)

10 mg IV or PO
QID,
before meals & at
bedtime

• Dopamine receptor antagonist & cholinergic stimulant
• Stimulates motility of upper GI
  tract
• Increases gastric contractions
• Increases gastric emptying and
  intestinal transit time
• Enhances LES pressure
• Blocks stimulation of CTZ		 EPS
Depression
Anxiety
Drowsiness
Galactorrhea
Amenorrhea
Gynecomastia 		• Crosses the BBB, increasing risk of CNS side effects.
• Higher risk of side effects in elderly due to   reduced drug clearance.
• Primarily renally eliminated; adjust dose in renal insufficiency (if CrCl < 50 ml/min, recommend
  half of usual dose).
• May exacerbate Parkinson's disease
symptoms and diminish effectiveness of dopamine agonists such as levodopa.

Bethanechol
(Urecholine®)

25 mg PO QID

 • Cholinergic agent
• Stimulants GI smooth muscle contraction
• Does not improve peristalsis
• Does not enhance GI transit
Abdominal
cramps
Diarrhea
Urinary fre-
quency
Nausea
Vomiting
Headache Hypertension
Blurred vision

• Motor stimulant rather than prokinetic agent.
• Use is limited by side effects.
• May be added to metoclopramide (when
side effects limit metoclopramide dose).

 

 

Erythromycin

Ethylsuccinate:
250 mg PO TID,
before meals
Lactobionate:
200 mg IV TID,
before meals

 • Mimics the effects of motilin on GI smooth muscle
• Stimulates gastric emtying
• May enhance esophageal contractions
• May increase LES pressure		 Nausea
GI upset

• Clinically ineffective for GERD.
• Used for treatment of diabetic gastroparesis.
• Monitor for drug interactions.
• May increase risk of antibiotic resistance development.
• Only macrolide currently used for its
prokinetic properties.

BBB=Blood brain barrier; CrCl=Creatinine clearances; CNS=Central nervous system; CTZ=Chemo-receptor trigger zone; EPS=Extrapyramidal symptoms;
GERD=Gastroesophageal reflux disease; GI=Gastrointestinal; LES=Lower esophageal sphincter

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