athiestjoe

athiestjoe

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Sep 24, 2024
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Metoclopramide in Your SN Protocol: A Safe Choice or a Risky Gamble?
Fact vs. Fear: Clarifying Misconceptions Around Meto, An Evidence-Based Approach

In this post, I am going to explore the safety of metoclopramide (aka meto) in light of the perceived risks many have around taking it, in particular to those believing it might cause some immediate, severe side effect which would impair their ability to complete their SN Protocol or have lasting effects if they decide to not ingest SN after taking meto (absolutely fine to abort the attempt). We will go over the background of the medication, common doses to as compared to the SN dosing, discuss the likelihood of side effects, the causes of the negative reputation it has, and ultimately make the reasonable conclusion that including it in an SN Protocol (or other stat usage) is not very likely to cause any serious adverse reaction. There are always exceptions to this generality, so be sure to consider your own medical situation and assess it in that context. For purposes of this post we are going to be focusing on oral (vs IM or IV) usage of metoclopramide given that is the route used in the SN Protocols.

For example, here are some posts of people who have expressed concern about meto and the side effects or harm from taking it: [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21].

Background On the Medication: Oral metoclopramide (Reglan, Maxolon, Perinorm, Metozolv ODT) is frequently prescribed for various gastrointestinal conditions, typically at doses ranging from 5 mg to 20 mg per dose with the standard maximum daily dose for most indications is 40 mg. However, for specific conditions such as gastroesophageal reflux disease (GERD), may recommend a higher maximum daily dose of 60 mg. In addition to GERD, metoclopramide is commonly used for a variety of other conditions. These include nausea and vomiting associated with chemotherapy (10mg is the usual oral single dose), radiotherapy, and postoperative recovery. On rare occasion in the emergency department it is also used 'off label' for migraine. Although, it is not a frontline pick for migraines and typically for this use case it would be an IV dose, not an oral dose.

The medication acts as a dopamine D2 receptor antagonist and prokinetic, which enhances gastric motility and accelerates gastric emptying. By inhibiting these receptors, metoclopramide not only enhances gastric motility but also produces antiemetic effects by acting on serotonin 5-HT3 receptors in the chemoreceptor trigger zone (CTZ) located in the area postrema of the brain. It causes prokinetic effects through a combination of actions: it inhibits presynaptic and postsynaptic D2 receptors, agonizes serotonin 5-HT4 receptors, and antagonizes muscarinic receptor inhibition. This interaction enhances the release of acetylcholine, which increases the tone of the lower esophageal sphincter (LES) and gastric tone, effectively accelerating gastric emptying and transit through the gut. In essence, meto counteracts the relaxant effects of dopamine on the gastrointestinal tract, promoting smoother movement of food and reducing feelings of nausea. This mechanism of action makes it particularly effective for treating conditions like diabetic gastroparesis and functional dyspepsia (10-20mg is a typical single, oral dose for that usage).

However, despite these typical guidelines, higher oral doses of metoclopramide, such as 50 mg and 100 mg and some upwards of 2-3mg/kg, have been evaluated in clinical contexts, particularly for postoperative nausea and vomiting (PONV).

SN Context Using 30 mg Dosing: A 30 mg dose is not truly that significantly higher than typical clinical doses, which often range from 10 mg to 20 mg and is below the threshold of some studies evaluating high-dose usage. Medications are designed to be overly safe, especially when considering that many people inadvertently double dose their medication having forgotten they took it or been confused by directions such as "Take 10mg three/four times per day" and inadvertently takes 3-4 tablets all at once, not realizing it was intended to be spread out. Or forgetting they took a 15mg already then took another 15mg? We would have substantial data and significant number of reports of serious side effects from those who did accidentally take more than they intended if it was truly a widespread issue. Imagine if someone who took a double oral dose of this medication were at all likely to suffer from quick, serious side effect?! The outrage would lead to it getting pulled from market.
  • Trial Data on Higher Oral Dosing than SN Protocol: A study that evaluated 50-100 mg doses found that about 9% of participants reported dystonia, indicating a relatively low rate of side effects even at doses higher than the SN Protocols. This greatly suggests the assertion I made earlier that the 30mg dose prior to SN is safe, effective, and not likely to yield any negative result that would impact the ability to finish the protocol.
  • There could always be the rare exception, especially if elderly or diabetic, however the data simply does not support this being something to be truly concerned about. And yes, there is still a chance of a side effect happening; that is always a possibility. Is it likely to kick in before taking the SN and somehow interfere with your ability to succeed? No.
About the Side Effects of Metoclopramide: Alright, with all that said above, let's dive a little bit into the possible side effects and evaluate the likelihood of them occurring so we have a fair view of the details!
  • Tardive Dyskinesia (TD): TD is more common with long-term use, with an incidence of 0.5% to 1%. Previous data provided a 1%-10% risk per national guidelines. Low dose for SN protocol or 30mg stat is not very likely to cause this side effect. Note, the word "tardive" specifically means "delayed reaction" so the symptom is not going to materialize right away anyways. Even if following a 48-hour regimen, the chances are still outstandingly low.
  • Dystonia: Very rare, and occurs in about 0.1% to 0.2% of patients.
  • Sedation and Fatigue: Found in 10% to 15% of patients. Not likely to make any noticeable difference for SN Protocol, especially if benzos are used. And once SN begins to work for CTB, there would be little to no attribution of this side effect to the metoclopramide.
  • Gastrointestinal Effects: Diarrhea occurs in 2% to 5% of users, although some have reported abdominal cramping in the 5% to 10% range.
  • Headache: A moderately common complain with different reports saying around 10% (1 in 10).
  • Neuroleptic Malignant Syndrome (NMS): Outstandingly rare reaction with an incidence of less than 0.01%.
  • Other: Allergic Reactions such as skin rash, itching, or swelling, though this is uncommon; cardiovascular effects such as irregular heartbeats or changes in blood pressure can occur but are rare. If you have underlying health issues, then this may be a possible concern. But if your body is sensitive or has known problems with medications, then it's likely not just this drug that would be at play to be worrisome in general. You know your own health situation better, and this is just a broad stroke discussion.
  • Additionally, I have yet to come upon any medical journal cases of TD, dystonia or akathisia aka EPS (extrapyramidal symptoms) from any single, oral dose of metoclopramide, even at a higher dose. On this site, one user did express they experienced some side effects [1] a few hours after taking meto including seeming EPS and another user expressing akathisia symptoms [2] Another member said they experienced dystonia from meto but was their first and only post (unreliable anecdote) on this site [3]. However, that or any other accounts seem to be extremely few and far between. You can make your own decision based on research if this a mild concern for you and I am not going to evaluate the pros/cons of stat vs 48-hour regimen as the reasonable conclusion that in either protocol is that it is not likely to happen. Yes, you can probably find some single, one-off horror stories. Those should be considered just that.
Onset Times for Side Effects and Relation to SN Protocol
But Why So Many Side Effects Listed for the Med? Simple, avoiding lawsuits & liability! Same reason why Tylenol says it may cause death despite only 500 people per year dying from it (half intentional) in America despite 60 million people taking per week. Pick a medication, any medication and look at the side effects, but just because it is listed or has happened in others does not mean it is that likely to happen for you, it is their way to avoiding liability in case it did happen, even if the chance is remote. The concern about side effects, especially tardive dyskinesia, is largely associated with long-term use. The FDA recommends limiting metoclopramide treatment to a maximum of 12 weeks due to these risks. Studies show that older adults and individuals with diabetes are more susceptible to TD. Case reports for single dose side effects are (with exception) particularly regarding IM/IV, not oral, doses. In context, this should be considered as well when evaluating the overall risk if you are concerned about it. The reality is that a single, high dose or even the regular, normal doses for the 48-hour Protocol then 3x dose in the SN protocols are not very likely to yield any truly adverse effects from this medication.

About that Scary Black Box Warning: Prior to 2018, estimates suggested there were around 1,000 claims filed from 2005 to 2010, with many involving patients alleging they developed TD after long-term use. The black-box warning for Reglan that came out in 2009 was largely a response to those lawsuits about tardive dyskinesia. It was designed to make sure doctors and patients are aware of the risks involved. While it's super important for safety, it can also make people think that metoclopramide is way more dangerous than it actually is. In reality, for short periods the risks are outstandingly low (even at a 30mg stat dosing, which is anywhere from 2-3x higher than the prescribed clinical use, as discussed above). It's just one of those situations where the warning, to mitigate liability for the manufacturer, can create a bit of unnecessary fear around the medication.

What do Studies About it Show?: A retrospective study from the UK reported that out of 15.9 million prescriptions, only 455 cases of dystonia and 4 cases of tardive dyskinesia were documented (70% were female), indicating a very low incidence relative to the extensive use of the drug. That is about 1 in 34,966. Other studies have side effects way higher suggesting about 1:500 but note this is for any adverse reaction (headache, diarrhea, fatigue, etc). To put this in context for SN, SN itself can and does cause headache, fatigue, and so identifying the difference in what is caused by Metoclopramide over the SN itself is somewhat impossible. Again, given the timing this would be taken before the SN, it is very unlikely any slight chance of a side effect would impair the ability to complete this method.

Perspective on Number of Prescriptions vs Serious Side Effects: Between 2013-2018, ~1.8 million prescriptions were given for metoclopramide annually in the United States alone. In 2018, there were significant legal settlements involving metoclopramide, including around 1,700 cases, bringing a lot of public concern over side effects and their associated risks due to the visibility of the lawsuits. This caused a dip in the annual prescriptions, followed by a dip in 2020; however, by 2022 the annual prescription number increased to ~1.3 million. These lawsuits have primarily involved claims of tardive dyskinesia and other neurological effects, which skewed public perception of the drug's safety. Even if every single one of those cases had definitive proof of this side effect (and let's assume they do), taken contextually for the millions of prescriptions given, we can see just how exceedingly rare it is. If more people truly experienced this, we would have seen significantly more litigants especially in America which is notoriously 'sue happy'.

Let's compare this a little bit with another popular AE for SN Protocols: Domperidone (Motilium). This is going to be a very short discussion just to add a little context and I encourage anyone to do their own additional research, here I am just going to make some broad stroke considerations to hopefully make the point quickly. Like metoclopramide, domperidone is a dopamine D2 receptor antagonist and prokinetic. It is banned in the United States due to risk of cardiac events for general use*, yet remains available in many other countries (UK, Canada, EU, elsewhere). It remains available in the United States as a medication under expanded access for gastrointestinal mobility However, it is also important to remember this: Domperidone was never approved in the US for general use to begin with anyways. Studies indicated that *Domperidone could increase the risk of serious heart issues, including arrhythmias and sudden cardiac arrest, especially in higher doses or in patients with preexisting heart conditions. In 2004, the FDA issued a warning about the potential cardiac risks associated with Domperidone for women taking it for milk production. In 2014, it was formally prohibited from being sold in the U.S., primarily due to these safety concerns particularly among cancer patients who had been prescribed it for nausea and vomiting. Does this mean domperidone is severely dangerous and is going to cause this? Perhaps if you have heart issues. Or are a cancer patient. Or maybe a breast-feeding mother. Even then, it is just an increased risk, not a categorical reaction you will experience. Its ban in the U.S. was primarily due to concerns about serious cardiac risks, especially when compared to its relatively limited use. Meaning it was easier to ban a drug that did not even have general approval for use anyways than spend time, money, and research into its safety than to keep it on the market in America.

Ultimately, in weighing the evidence, it appears that while there are risks associated with metoclopramide, particularly with long-term use, the actual incidence of serious side effects remains relatively low. I may not have covered every single concern around this but tried to take a birds-eye view on this discussion to help set aside the concerns. Keep in mind that the usage of this medication for these protocols is outstandingly brief (further reduced for the Stat Protocol) so the likelihood of them happening in the timeframe before using SN is already outstandingly low. Given the usage in an SN protocol is brief, not outrageously above the 'normal' therapeutic dose, lack of time for side effects to even materialize, it absolutely is a 'safe' addition to the protocol and users should not be concerned around its limited usage here. The lawsuits and subsequent black-box warnings have contributed to a heightened perception of risk, which do not fully align with the clinical realities and millions upon millions of users and doses taken over the decades it has been used.

Hopefully this puts some ease and comfort around the usage of metoclopramide for anyone who had concern around it now that we are a little bit more armed with the facts and about this medication.
 
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howunfortunateforme

Experienced
Oct 2, 2024
257
I had eps syntoms after one dose and it was horrible nausea pacing vomiting rocking panic it's real
 
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suffering_mo

Specialist
May 8, 2024
361
I had eps syntoms after one dose and it was horrible nausea pacing vomiting rocking panic it's real
Was it oral dose or via IV? If oral, do you remember the dosage?

I completely believe you. Some of us, especially those of us who are very sensitive, are often more impacted by these meds.
 
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howunfortunateforme

Experienced
Oct 2, 2024
257
Was it oral dose or via IV? If oral, do you remember the dosage?

I completely believe you. Some of us, especially those of us who are very sensitive, are often more impacted by these meds.
I dont remember but it was bad so I feel
Like that would mess up sn
 
Plato'sCaveDweller

Plato'sCaveDweller

Sleep is good, death is better.
Sep 2, 2024
513
I am glad you made this post. Not everyone is aware of the risks and adverse reactions (albeit rare, as shown in this post) of Meto, and those that do become aware can become worried and hesitant to use it in their protocol. This post, in my opinion, sufficiently addresses concerns one may have regarding the medication. Hopefully, anyone that comes across this post and has the same concerns that I had can ease their fears and regain confidence in their protocol (whatever method it may be that involves Meto).
 
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howunfortunateforme

Experienced
Oct 2, 2024
257
Within a couple of hours
 
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howunfortunateforme

Experienced
Oct 2, 2024
257
Ah, gotcha. This is important info, so thank you for sharing. I am very sorry you had such a horrible reaction to the medication :(
Thank you so now im
Wondering if I can use seroquel didn't have reaction to that one
 
LunarLight

LunarLight

i'm a loser, a failure
Apr 3, 2024
1,368
Yet another outstanding thread by atheistjoe! Bookmarked, it's gonna prove useful very soon! Thank you for fighting so hard this plague known on here as useless fearmongering.
 
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athiestjoe

athiestjoe

Passenger
Sep 24, 2024
410
I dont remember but it was bad so I feel
Within a couple of hours
I think it was iv "migraine cocktail" which started this whole pharma situation
Wondering if I can use seroquel didn't have reaction to that one

I'm truly sorry to hear about your rare negative experience. However, if it took several hours for an IV dose to cause a side effect, then taking an oral dose 40-45 minutes before SN is unlikely to result in a significant reaction that would affect the ability to CTB. Just a perspective to consider given why someone is taking meto for the SN Protocol, they wouldn't be alive and kicking by the time that slight adverse reaction is likely to occur; again just a hypothetical scenario. That said, it's still a possibility, so it's important to weigh the pros and cons based on your unique and very individual situation. If it was part of a cocktail, it can be challenging to pinpoint which medication might have caused the adverse reaction, as it's difficult to blame a specific drug without clear evidence. Although the common cocktail given in America anyways has two other medications which are not likely to cause EPS symptoms but in someone with an NSAID or steroid issue could result in nausea and vomiting or other side effects. EPS can be difficult to distinguish from psychiatric symptoms FYI including anxiety and I would imagine that serious of a migraine and being in a hospital would make a lot of people anxious. I am so sorry you went through that. Also, the steroids given in those cocktails also could lead to the pacing/restlessness. Considering you had that severe of a migraine to land in an ER, and that severe for them to treat it with something IV (given how long it takes to get admitted, a migraine being a very low priority in an ER so waiting around an ample time while more critical patients were treated, the time to get in the ER, the time to have your medical history, stats, setting up the IV, the time to get it from the hospital pharmacy, etc would all add up to quite some time) then it is feasible the side effects could have been unrelated to the medications anyways. Nausea and vomiting (possibly from the migraine itself or one of the other medications) and also anxiety (pacing) from being in pain and also in hospital or from the steroid in the cocktail...although it is pure speculation which doesn't get us too far unfortunately. It is truly difficult to pinpoint the cause. I completely hear and understand your concerns, so I encourage you to do further research to determine what's best for you. Just wanted to be thoughtful on this situation since you raised concern and I certainly do not have any firm answers just offering a perspective. I am not trying to convince you, or anyone, meto is safe for your highly personalized factors, just giving a reply to outine some considerations I thought of in thinking about the situation.

However, with all that said, it would be a very good idea to go and review some helpful tips found on the site about quetiapine (Seroquel) and you may want to consider why medications work as effective antiemetics (AEs) for SN protocols: among other factors what is particularly helpful is the blocking of D2 dopamine receptors. Then, consider why EPS side effects could occur, albeit extremely rarely. EPS may occur largely because of this dopamine blockade. While is true that Seroquel generally has a lower propensity for causing EPS compared to other antipsychotic medications (emphasis added as now this is a general comparison of Seroquel to other antipsychotics, not specific AEs), as its serotonin receptor antagonism can help mitigate some of the dopaminergic side effects. But EPS is primarily associated with medications that block dopamine receptors, such as antipsychotics (aka, applicable for this convo- Seroquel) and certain antiemetics (aka, applicable for this convo - Meto). Therefore, the same concern about why not use metoclopramide applies to why you would consider taking Seroquel for this purpose—specifically, the blocking of D2 receptors to get the desired AE effect. Ultimately, however, in addition to the D2 aspect, metoclopramide's advantage lies in its additional support from antagonism of serotonin 5-HT3 receptors (which helps reduce nausea) and more importantly agonism of serotonin 5-HT4 receptors (which promotes gastrointestinal motility) which Seroquel does not additionally provide, and all 3 of those (again, most importantly the D2 dopamine side) making meto a vasly superior option if the other option considered is Seroquel. This leads into though importantly why other AEs, such as for instance Zofran, are not as effective. Although Ondansetron does target 5-HT3 receptors, which are involved in the vomiting reflex and nausea, it does not provide any benefit on the most important side in that it does not have any direct prokinetic effects as it won't speed up gastric motility like metoclopramide or domperidone since it does not block D2 receptors. Of course, any antiemetic is certainly preferable to not having one at all but the reason behind taking certain AEs is due to the specific benefit outlined at the top of this paragraph. I realize that is a lot information so let me try to say it one last time and more clearly: if you are taking a medication with the goal of having success with SN, it needs to be a D2 dopamine antagonist to work and that same mechanism is the reason what could, ever so minimal of a chance, cause EPS symptoms. If you did in fact have a reaction caused by meto in the past, changing the medication itself is probably not going to affect the end result and eliminate that same risk of another medication causing it if that medication is doing the same interference where it matters for SN protocol AE purposes. Just a consideration and take it at face value since there are simply too many factors at play for me or anyone to chime in more specifically for your unique circumstances, sorry about that.

If you have some specific medical conditions that has previously resulted in concerning outcomes or adverse reactions, it's crucial to factor that into your decision-making process. Take the time to thoroughly evaluate the potential risks in relation to your unique circumstances, and carefully consider whether this concern is significant enough to warrant exploring alternative methods for CTB. This is a very general explaination which I hope is possibly helpful.

With whatever you decide, I hope you find peace & serenity.
 
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howunfortunateforme

Experienced
Oct 2, 2024
257
Very helpful. It wasn't even a migraine it was a bad headache and some nausea and they gave me that cocktail which essentially ruined me bc led me down of a path of psych meds. How do I get meto then? Pcp? Psych? Is it really worth it? I've seen people on here say they throw up no matter what.
 
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Unspoken7612

Specialist
Jul 14, 2024
358
The one thing I will say is that if you are taking psychiatric meds, it is worth taking a small "test dose" of meto a day or so before any planned attempt, just to see if you experience unpleasant serotonergic symptoms.

I'd say the main weakness of the opening post is that it doesn't talk about drug interactions.

Most people on SSRIs and similar should be fine, but there is an increased risk of nausea and similar.
 
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howunfortunateforme

Experienced
Oct 2, 2024
257
The one thing I will say is that if you are taking psychiatric meds, it is worth taking a small "test dose" of meto a day or so before any planned attempt, just to see if you experience unpleasant serotonergic symptoms.

I'd say the main weakness of the opening post is that it doesn't talk about drug interactions.

Most people on SSRIs and similar should be fine, but there is an increased risk of nausea and similar.
How do I get it though? Just call Neuro and ask for
Meto? Is caused severe akathisia for
Me and skyrockets my heart rate
 
athiestjoe

athiestjoe

Passenger
Sep 24, 2024
410
I am glad you made this post. Not everyone is aware of the risks and adverse reactions (albeit rare, as shown in this post) of Meto, and those that do become aware can become worried and hesitant to use it in their protocol. This post, in my opinion, sufficiently addresses concerns one may have regarding the medication. Hopefully, anyone that comes across this post and has the same concerns that I had can ease their fears and regain confidence in their protocol (whatever method it may be that involves Meto).
It's truly my pleasure, my friend! Thank you for your amazing support. This site is full of amazing gems like you. I hope this helps ease some fears and anxieties and ultimately benefits others as well (with whatever they decide).

Yet another outstanding thread by atheistjoe! Bookmarked, it's gonna prove useful very soon! Thank you for fighting so hard this plague known on here as useless fearmongering.
Of course, LunarLight! Your kind words are noticed and it is the least I could do to contribute something here like so many before me have been thoughtful in doing. Figured I may as well make myself as useful as possible before my own time comes up!
 
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Unspoken7612

Specialist
Jul 14, 2024
358
How do I get it though? Just call Neuro and ask for
Meto? Is caused severe akathisia for
Me and skyrockets my heart rate
I personally brought it online, from an Indian pharmacist. This is a risky endeavour because frankly they're sketchy.

Some people will tell their GP that they have been having nausea accompanying migraines. A relative has the same condition and saw a big improvement with meto. This is not guaranteed to work (especially if you are on psychiatric meds!) but has a better chance than saying you are travel sick.
 
H

howunfortunateforme

Experienced
Oct 2, 2024
257
This won't work im
On too many psych meds
 
S

saltytears

Member
Aug 22, 2024
59
Metoclopramide in Your SN Protocol: A Safe Choice or a Risky Gamble?
Fact vs. Fear: Clarifying Misconceptions Around Meto, An Evidence-Based Approach

In this post, I am going to explore the safety of metoclopramide (aka meto) in light of the perceived risks many have around taking it, in particular to those believing it might cause some immediate, severe side effect which would impair their ability to complete their SN Protocol or have lasting effects if they decide to not ingest SN after taking meto (absolutely fine to abort the attempt). We will go over the background of the medication, common doses to as compared to the SN dosing, discuss the likelihood of side effects, the causes of the negative reputation it has, and ultimately make the reasonable conclusion that including it in an SN Protocol (or other stat usage) is not very likely to cause any serious adverse reaction. There are always exceptions to this generality, so be sure to consider your own medical situation and assess it in that context. For purposes of this post we are going to be focusing on oral (vs IM or IV) usage of metoclopramide given that is the route used in the SN Protocols.

For example, here are some posts of people who have expressed concern about meto and the side effects or harm from taking it: [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21].

Background On the Medication: Oral metoclopramide (Reglan, Maxolon, Perinorm, Metozolv ODT) is frequently prescribed for various gastrointestinal conditions, typically at doses ranging from 5 mg to 20 mg per dose with the standard maximum daily dose for most indications is 40 mg. However, for specific conditions such as gastroesophageal reflux disease (GERD), may recommend a higher maximum daily dose of 60 mg. In addition to GERD, metoclopramide is commonly used for a variety of other conditions. These include nausea and vomiting associated with chemotherapy (10mg is the usual oral single dose), radiotherapy, and postoperative recovery. On rare occasion in the emergency department it is also used 'off label' for migraine. Although, it is not a frontline pick for migraines and typically for this use case it would be an IV dose, not an oral dose.

The medication acts as a dopamine D2 receptor antagonist and prokinetic, which enhances gastric motility and accelerates gastric emptying. By inhibiting these receptors, metoclopramide not only enhances gastric motility but also produces antiemetic effects by acting on serotonin 5-HT3 receptors in the chemoreceptor trigger zone (CTZ) located in the area postrema of the brain. It causes prokinetic effects through a combination of actions: it inhibits presynaptic and postsynaptic D2 receptors, agonizes serotonin 5-HT4 receptors, and antagonizes muscarinic receptor inhibition. This interaction enhances the release of acetylcholine, which increases the tone of the lower esophageal sphincter (LES) and gastric tone, effectively accelerating gastric emptying and transit through the gut. In essence, meto counteracts the relaxant effects of dopamine on the gastrointestinal tract, promoting smoother movement of food and reducing feelings of nausea. This mechanism of action makes it particularly effective for treating conditions like diabetic gastroparesis and functional dyspepsia (10-20mg is a typical single, oral dose for that usage).

However, despite these typical guidelines, higher oral doses of metoclopramide, such as 50 mg and 100 mg and some upwards of 2-3mg/kg, have been evaluated in clinical contexts, particularly for postoperative nausea and vomiting (PONV).

SN Context Using 30 mg Dosing: A 30 mg dose is not truly that significantly higher than typical clinical doses, which often range from 10 mg to 20 mg and is below the threshold of some studies evaluating high-dose usage. Medications are designed to be overly safe, especially when considering that many people inadvertently double dose their medication having forgotten they took it or been confused by directions such as "Take 10mg three/four times per day" and inadvertently takes 3-4 tablets all at once, not realizing it was intended to be spread out. Or forgetting they took a 15mg already then took another 15mg? We would have substantial data and significant number of reports of serious side effects from those who did accidentally take more than they intended if it was truly a widespread issue. Imagine if someone who took a double oral dose of this medication were at all likely to suffer from quick, serious side effect?! The outrage would lead to it getting pulled from market.
  • Trial Data on Higher Oral Dosing than SN Protocol: A study that evaluated 50-100 mg doses found that about 9% of participants reported dystonia, indicating a relatively low rate of side effects even at doses higher than the SN Protocols. This greatly suggests the assertion I made earlier that the 30mg dose prior to SN is safe, effective, and not likely to yield any negative result that would impact the ability to finish the protocol.
  • There could always be the rare exception, especially if elderly or diabetic, however the data simply does not support this being something to be truly concerned about. And yes, there is still a chance of a side effect happening; that is always a possibility. Is it likely to kick in before taking the SN and somehow interfere with your ability to succeed? No.
About the Side Effects of Metoclopramide: Alright, with all that said above, let's dive a little bit into the possible side effects and evaluate the likelihood of them occurring so we have a fair view of the details!
  • Tardive Dyskinesia (TD): TD is more common with long-term use, with an incidence of 0.5% to 1%. Previous data provided a 1%-10% risk per national guidelines. Low dose for SN protocol or 30mg stat is not very likely to cause this side effect. Note, the word "tardive" specifically means "delayed reaction" so the symptom is not going to materialize right away anyways. Even if following a 48-hour regimen, the chances are still outstandingly low.
  • Dystonia: Very rare, and occurs in about 0.1% to 0.2% of patients.
  • Sedation and Fatigue: Found in 10% to 15% of patients. Not likely to make any noticeable difference for SN Protocol, especially if benzos are used. And once SN begins to work for CTB, there would be little to no attribution of this side effect to the metoclopramide.
  • Gastrointestinal Effects: Diarrhea occurs in 2% to 5% of users, although some have reported abdominal cramping in the 5% to 10% range.
  • Headache: A moderately common complain with different reports saying around 10% (1 in 10).
  • Neuroleptic Malignant Syndrome (NMS): Outstandingly rare reaction with an incidence of less than 0.01%.
  • Other: Allergic Reactions such as skin rash, itching, or swelling, though this is uncommon; cardiovascular effects such as irregular heartbeats or changes in blood pressure can occur but are rare. If you have underlying health issues, then this may be a possible concern. But if your body is sensitive or has known problems with medications, then it's likely not just this drug that would be at play to be worrisome in general. You know your own health situation better, and this is just a broad stroke discussion.
  • Additionally, I have yet to come upon any medical journal cases of TD, dystonia or akathisia aka EPS (extrapyramidal symptoms) from any single, oral dose of metoclopramide, even at a higher dose. On this site, one user did express they experienced some side effects [1] a few hours after taking meto including seeming EPS and another user expressing akathisia symptoms [2] Another member said they experienced dystonia from meto but was their first and only post (unreliable anecdote) on this site [3]. However, that or any other accounts seem to be extremely few and far between. You can make your own decision based on research if this a mild concern for you and I am not going to evaluate the pros/cons of stat vs 48-hour regimen as the reasonable conclusion that in either protocol is that it is not likely to happen. Yes, you can probably find some single, one-off horror stories. Those should be considered just that.
Onset Times for Side Effects and Relation to SN Protocol
But Why So Many Side Effects Listed for the Med? Simple, avoiding lawsuits & liability! Same reason why Tylenol says it may cause death despite only 500 people per year dying from it (half intentional) in America despite 60 million people taking per week. Pick a medication, any medication and look at the side effects, but just because it is listed or has happened in others does not mean it is that likely to happen for you, it is their way to avoiding liability in case it did happen, even if the chance is remote. The concern about side effects, especially tardive dyskinesia, is largely associated with long-term use. The FDA recommends limiting metoclopramide treatment to a maximum of 12 weeks due to these risks. Studies show that older adults and individuals with diabetes are more susceptible to TD. Case reports for single dose side effects are (with exception) particularly regarding IM/IV, not oral, doses. In context, this should be considered as well when evaluating the overall risk if you are concerned about it. The reality is that a single, high dose or even the regular, normal doses for the 48-hour Protocol then 3x dose in the SN protocols are not very likely to yield any truly adverse effects from this medication.

About that Scary Black Box Warning: Prior to 2018, estimates suggested there were around 1,000 claims filed from 2005 to 2010, with many involving patients alleging they developed TD after long-term use. The black-box warning for Reglan that came out in 2009 was largely a response to those lawsuits about tardive dyskinesia. It was designed to make sure doctors and patients are aware of the risks involved. While it's super important for safety, it can also make people think that metoclopramide is way more dangerous than it actually is. In reality, for short periods the risks are outstandingly low (even at a 30mg stat dosing, which is anywhere from 2-3x higher than the prescribed clinical use, as discussed above). It's just one of those situations where the warning, to mitigate liability for the manufacturer, can create a bit of unnecessary fear around the medication.

What do Studies About it Show?: A retrospective study from the UK reported that out of 15.9 million prescriptions, only 455 cases of dystonia and 4 cases of tardive dyskinesia were documented (70% were female), indicating a very low incidence relative to the extensive use of the drug. That is about 1 in 34,966. Other studies have side effects way higher suggesting about 1:500 but note this is for any adverse reaction (headache, diarrhea, fatigue, etc). To put this in context for SN, SN itself can and does cause headache, fatigue, and so identifying the difference in what is caused by Metoclopramide over the SN itself is somewhat impossible. Again, given the timing this would be taken before the SN, it is very unlikely any slight chance of a side effect would impair the ability to complete this method.

Perspective on Number of Prescriptions vs Serious Side Effects: Between 2013-2018, ~1.8 million prescriptions were given for metoclopramide annually in the United States alone. In 2018, there were significant legal settlements involving metoclopramide, including around 1,700 cases, bringing a lot of public concern over side effects and their associated risks due to the visibility of the lawsuits. This caused a dip in the annual prescriptions, followed by a dip in 2020; however, by 2022 the annual prescription number increased to ~1.3 million. These lawsuits have primarily involved claims of tardive dyskinesia and other neurological effects, which skewed public perception of the drug's safety. Even if every single one of those cases had definitive proof of this side effect (and let's assume they do), taken contextually for the millions of prescriptions given, we can see just how exceedingly rare it is. If more people truly experienced this, we would have seen significantly more litigants especially in America which is notoriously 'sue happy'.

Let's compare this a little bit with another popular AE for SN Protocols: Domperidone (Motilium). This is going to be a very short discussion just to add a little context and I encourage anyone to do their own additional research, here I am just going to make some broad stroke considerations to hopefully make the point quickly. Like metoclopramide, domperidone is a dopamine D2 receptor antagonist and prokinetic. It is banned in the United States due to risk of cardiac events for general use*, yet remains available in many other countries (UK, Canada, EU, elsewhere). It remains available in the United States as a medication under expanded access for gastrointestinal mobility However, it is also important to remember this: Domperidone was never approved in the US for general use to begin with anyways. Studies indicated that *Domperidone could increase the risk of serious heart issues, including arrhythmias and sudden cardiac arrest, especially in higher doses or in patients with preexisting heart conditions. In 2004, the FDA issued a warning about the potential cardiac risks associated with Domperidone for women taking it for milk production. In 2014, it was formally prohibited from being sold in the U.S., primarily due to these safety concerns particularly among cancer patients who had been prescribed it for nausea and vomiting. Does this mean domperidone is severely dangerous and is going to cause this? Perhaps if you have heart issues. Or are a cancer patient. Or maybe a breast-feeding mother. Even then, it is just an increased risk, not a categorical reaction you will experience. Its ban in the U.S. was primarily due to concerns about serious cardiac risks, especially when compared to its relatively limited use. Meaning it was easier to ban a drug that did not even have general approval for use anyways than spend time, money, and research into its safety than to keep it on the market in America.

Ultimately, in weighing the evidence, it appears that while there are risks associated with metoclopramide, particularly with long-term use, the actual incidence of serious side effects remains relatively low. I may not have covered every single concern around this but tried to take a birds-eye view on this discussion to help set aside the concerns. Keep in mind that the usage of this medication for these protocols is outstandingly brief (further reduced for the Stat Protocol) so the likelihood of them happening in the timeframe before using SN is already outstandingly low. Given the usage in an SN protocol is brief, not outrageously above the 'normal' therapeutic dose, lack of time for side effects to even materialize, it absolutely is a 'safe' addition to the protocol and users should not be concerned around its limited usage here. The lawsuits and subsequent black-box warnings have contributed to a heightened perception of risk, which do not fully align with the clinical realities and millions upon millions of users and doses taken over the decades it has been used.

Hopefully this puts some ease and comfort around the usage of metoclopramide for anyone who had concern around it now that we are a little bit more armed with the facts and about this medication.
Seems like from few threads Ive read documenting SN ingestion, even those taking METO end up vomiting and moving on to 2nd cup SN. Is it necessary to even take it? I cant get it, but have Zofran....Can I take the Zofran instead or should I take nothing? HOw much Zofran? Just looking for answers from someone who might know the mechanisms. TY
 
H

howunfortunateforme

Experienced
Oct 2, 2024
257
Seems like from few threads Ive read documenting SN ingestion, even those taking METO end up vomiting and moving on to 2nd cup SN. Is it necessary to even take it? I cant get it, but have Zofran....Can I take the Zofran instead or should I take nothing? HOw much Zofran? Just looking for answers from someone who might know the mechanisms. TY
This is what I need to know asap although my order says awaiting processing
 
opheliaoveragain

opheliaoveragain

Eating Disordered Junkie
Jun 2, 2024
1,282
Thank you for this, OP! Bookmarking!
 
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athiestjoe

athiestjoe

Passenger
Sep 24, 2024
410
I'd say the main weakness of the opening post is that it doesn't talk about drug interactions.
Thank you for raising this point. Everyone understands the importance of checking for drug interactions and my post was specifically around the perceived dangers of it. But, generally, if someone is taking pretty routine medications or over-the-counter medications in the days leading up to their SN protocol, the risk of experiencing a serious, immediate side effect from metoclopramide is extremely low, especially within the 40-45 minutes after taking it with a stat dose (for example). Perhaps the stat dose has the edge for people on a ton of medications who have some wild concern about interactions! It's crucial to remember that just because a potential interaction exists doesn't mean one should panic or exclude it without context. While consulting an interaction database is wise for those on multiple medications, further research is essential.

Ultimately, the overwhelming vast majority of people on common medications won't face significant issues. For those who are worried, stopping another medication ahead of time—if safe—while considering its half-life & metabolic rate (elimination) might be worth it. Or take a test dose. I just do not see the extreme benefit in that but if it gives someone peace of mind and comfort to test meto, go for it. However, for the majority, this step is quite unnecessary. Everyone should consider their own health/routine drugs and make their own reasonably informed decisions. The likelihood of a severe side effect preventing someone from completing the SN protocol after a stat dose is ridiculously low, but it's always possible. My post aimed to provide a general perspective, and unique circumstances should be evaluated individually.

Thanks for your comment, and I hope this helps!

It wasn't even a migraine it was a bad headache and some nausea and they gave me that cocktail which essentially ruined me bc led me down of a path of psych meds. How do I get meto then? Pcp? Psych?
How do I get meto then?
This won't work im
On too many psych meds
This is what I need to know asap although my order says awaiting processing
Interesting it was apparently given if it wasn't even a migraine (even if it was, still not top choice). I am sorry you went through that. Talk to your GP or PCP. Ultimately, you need to make your own decisions. I'm sorry to hear you're struggling. You've gone in many different directions in your comments, so I encourage you to use the site's search feature to find helpful resources to help you decide whatever you want to decide. Good luck.


Seems like from few threads Ive read documenting SN ingestion, even those taking METO end up vomiting and moving on to 2nd cup SN. Is it necessary to even take it? I cant get it, but have Zofran....Can I take the Zofran instead or should I take nothing? HOw much Zofran? Just looking for answers from someone who might know the mechanisms. TY
Let me try to address these questions.

Question 1 - essentially "is it necessary" - while it is technically not mandatory, I think the reason it is highly, highly suggested is pretty understandable. Given people did succeed without any AE (and people who took AEs still mostly all vomited, really signals to me that the risk of vomiting is likely, so while some could argue if "I am going to throw up anyways, what's the point?" I would disagree and say it isn't the vomiting alone that is important but also because meto (or dom or another D2 antagonist) not just provide the nausea benefit but specifically the prokinetic benefit which helps it reach the intestine quicker which is where it is actually absorbed by the body. The quicker it is out of the stomach, the better). But no, it is not required. Just strongly suggested with a few reasons behind it.

Question 2 - "Can I take Zofran instead or should I take nothing?" In one of my replies above I brought up Zofran for another user. The shorter version: while Zofran could help with serotonin-mediated nausea (specifically 5-HT3) which are involved in some vomiting reflexes and nausea, it is not as effective as metoclopramide or domperidone given Ondansetron does not provide any benefit on the D2 receptors in the chemoreceptor trigger zone and Zofran has absolutely no prokinetic effect and won't help with gastric emptying. Zofran is better suited for a few types of nausea like chemotherapy, post op nausea & vomiting (PONV), gastro irritation (food poisoning) as they activate the 5-HT3 receptors for those things causing nausea & vomiting. While true it is possible SN would cause gastro irritation and might release some serotonin causing nausea and vomiting, the real benefit of an effective AE would be one like meto or dom which also impact those receptors in addition to the D2 ones which importantly is the one to help with gastric emptying. But meto does also work on serotonin in addition to dopamine receptors. But, it would not hurt anything by adding it to a protocol. Do I think it would provide any real benefit that we find useful? Also, probably not. Ultimately some AE is better than no AE although some have succeeded without any AE. It is truly up to each person to evaluate the risks themselves and whether they want to increase the risk of failure.

Question 3 - "How much Zofran?" Well since I do not particularly think it will be of any big benefit I am hesistant to offer any sort of protocol suggestion around it. Someone could consider taking it 24-48 hours in advance to make sure it is completely in the system.

Hope that somewhat helps!

Thank you for this, OP! Bookmarking!
As always, my pleasure indeed!! Thanks for taking the time out of your busy day to comment!
 
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HD72

HD72

Humpty Dumpty had a great fall
Sep 10, 2023
294
I have dystonia akathisia tardive dyskinesia. It's. Why I want to die. Which med caused it. Don't know. Don't care. Just wish I had a gun to end it all. 4 years and counting. Each day worse. I'm trying to get the courage to do night night. I can't take this life. I'd say god bless anyone who has this but I believe god is a sick twisted MF who invented illnesses like this cuz he gets bored and likes to watch us suffer.
 
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whydidthishappen

whydidthishappen

Cut open
May 6, 2024
74
The one thing I will say is that if you are taking psychiatric meds, it is worth taking a small "test dose" of meto a day or so before any planned attempt, just to see if you experience unpleasant serotonergic symptoms.

I'd say the main weakness of the opening post is that it doesn't talk about drug interactions.

Most people on SSRIs and similar should be fine, but there is an increased risk of nausea and similar.
I am taking 150 mg Zoloft. I will take a test dose tomorrow of domperidone. I need to test it anyway due to my source of a pharma retailer abroad. I wonder if anyone here has has had to resort to getting the anti emetic this way?
 
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isolatedl111

isolatedl111

Experienced
Nov 25, 2024
200
Metoclopramide in Your SN Protocol: A Safe Choice or a Risky Gamble?
Fact vs. Fear: Clarifying Misconceptions Around Meto, An Evidence-Based Approach

In this post, I am going to explore the safety of metoclopramide (aka meto) in light of the perceived risks many have around taking it, in particular to those believing it might cause some immediate, severe side effect which would impair their ability to complete their SN Protocol or have lasting effects if they decide to not ingest SN after taking meto (absolutely fine to abort the attempt). We will go over the background of the medication, common doses to as compared to the SN dosing, discuss the likelihood of side effects, the causes of the negative reputation it has, and ultimately make the reasonable conclusion that including it in an SN Protocol (or other stat usage) is not very likely to cause any serious adverse reaction. There are always exceptions to this generality, so be sure to consider your own medical situation and assess it in that context. For purposes of this post we are going to be focusing on oral (vs IM or IV) usage of metoclopramide given that is the route used in the SN Protocols.

For example, here are some posts of people who have expressed concern about meto and the side effects or harm from taking it: [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21].

Background On the Medication: Oral metoclopramide (Reglan, Maxolon, Perinorm, Metozolv ODT) is frequently prescribed for various gastrointestinal conditions, typically at doses ranging from 5 mg to 20 mg per dose with the standard maximum daily dose for most indications is 40 mg. However, for specific conditions such as gastroesophageal reflux disease (GERD), may recommend a higher maximum daily dose of 60 mg. In addition to GERD, metoclopramide is commonly used for a variety of other conditions. These include nausea and vomiting associated with chemotherapy (10mg is the usual oral single dose), radiotherapy, and postoperative recovery. On rare occasion in the emergency department it is also used 'off label' for migraine. Although, it is not a frontline pick for migraines and typically for this use case it would be an IV dose, not an oral dose.

The medication acts as a dopamine D2 receptor antagonist and prokinetic, which enhances gastric motility and accelerates gastric emptying. By inhibiting these receptors, metoclopramide not only enhances gastric motility but also produces antiemetic effects by acting on serotonin 5-HT3 receptors in the chemoreceptor trigger zone (CTZ) located in the area postrema of the brain. It causes prokinetic effects through a combination of actions: it inhibits presynaptic and postsynaptic D2 receptors, agonizes serotonin 5-HT4 receptors, and antagonizes muscarinic receptor inhibition. This interaction enhances the release of acetylcholine, which increases the tone of the lower esophageal sphincter (LES) and gastric tone, effectively accelerating gastric emptying and transit through the gut. In essence, meto counteracts the relaxant effects of dopamine on the gastrointestinal tract, promoting smoother movement of food and reducing feelings of nausea. This mechanism of action makes it particularly effective for treating conditions like diabetic gastroparesis and functional dyspepsia (10-20mg is a typical single, oral dose for that usage).

However, despite these typical guidelines, higher oral doses of metoclopramide, such as 50 mg and 100 mg and some upwards of 2-3mg/kg, have been evaluated in clinical contexts, particularly for postoperative nausea and vomiting (PONV).

SN Context Using 30 mg Dosing: A 30 mg dose is not truly that significantly higher than typical clinical doses, which often range from 10 mg to 20 mg and is below the threshold of some studies evaluating high-dose usage. Medications are designed to be overly safe, especially when considering that many people inadvertently double dose their medication having forgotten they took it or been confused by directions such as "Take 10mg three/four times per day" and inadvertently takes 3-4 tablets all at once, not realizing it was intended to be spread out. Or forgetting they took a 15mg already then took another 15mg? We would have substantial data and significant number of reports of serious side effects from those who did accidentally take more than they intended if it was truly a widespread issue. Imagine if someone who took a double oral dose of this medication were at all likely to suffer from quick, serious side effect?! The outrage would lead to it getting pulled from market.
  • Trial Data on Higher Oral Dosing than SN Protocol: A study that evaluated 50-100 mg doses found that about 9% of participants reported dystonia, indicating a relatively low rate of side effects even at doses higher than the SN Protocols. This greatly suggests the assertion I made earlier that the 30mg dose prior to SN is safe, effective, and not likely to yield any negative result that would impact the ability to finish the protocol.
  • There could always be the rare exception, especially if elderly or diabetic, however the data simply does not support this being something to be truly concerned about. And yes, there is still a chance of a side effect happening; that is always a possibility. Is it likely to kick in before taking the SN and somehow interfere with your ability to succeed? No.
About the Side Effects of Metoclopramide: Alright, with all that said above, let's dive a little bit into the possible side effects and evaluate the likelihood of them occurring so we have a fair view of the details!
  • Tardive Dyskinesia (TD): TD is more common with long-term use, with an incidence of 0.5% to 1%. Previous data provided a 1%-10% risk per national guidelines. Low dose for SN protocol or 30mg stat is not very likely to cause this side effect. Note, the word "tardive" specifically means "delayed reaction" so the symptom is not going to materialize right away anyways. Even if following a 48-hour regimen, the chances are still outstandingly low.
  • Dystonia: Very rare, and occurs in about 0.1% to 0.2% of patients.
  • Sedation and Fatigue: Found in 10% to 15% of patients. Not likely to make any noticeable difference for SN Protocol, especially if benzos are used. And once SN begins to work for CTB, there would be little to no attribution of this side effect to the metoclopramide.
  • Gastrointestinal Effects: Diarrhea occurs in 2% to 5% of users, although some have reported abdominal cramping in the 5% to 10% range.
  • Headache: A moderately common complain with different reports saying around 10% (1 in 10).
  • Neuroleptic Malignant Syndrome (NMS): Outstandingly rare reaction with an incidence of less than 0.01%.
  • Other: Allergic Reactions such as skin rash, itching, or swelling, though this is uncommon; cardiovascular effects such as irregular heartbeats or changes in blood pressure can occur but are rare. If you have underlying health issues, then this may be a possible concern. But if your body is sensitive or has known problems with medications, then it's likely not just this drug that would be at play to be worrisome in general. You know your own health situation better, and this is just a broad stroke discussion.
  • Additionally, I have yet to come upon any medical journal cases of TD, dystonia or akathisia aka EPS (extrapyramidal symptoms) from any single, oral dose of metoclopramide, even at a higher dose. On this site, one user did express they experienced some side effects [1] a few hours after taking meto including seeming EPS and another user expressing akathisia symptoms [2] Another member said they experienced dystonia from meto but was their first and only post (unreliable anecdote) on this site [3]. However, that or any other accounts seem to be extremely few and far between. You can make your own decision based on research if this a mild concern for you and I am not going to evaluate the pros/cons of stat vs 48-hour regimen as the reasonable conclusion that in either protocol is that it is not likely to happen. Yes, you can probably find some single, one-off horror stories. Those should be considered just that.
Onset Times for Side Effects and Relation to SN Protocol
But Why So Many Side Effects Listed for the Med? Simple, avoiding lawsuits & liability! Same reason why Tylenol says it may cause death despite only 500 people per year dying from it (half intentional) in America despite 60 million people taking per week. Pick a medication, any medication and look at the side effects, but just because it is listed or has happened in others does not mean it is that likely to happen for you, it is their way to avoiding liability in case it did happen, even if the chance is remote. The concern about side effects, especially tardive dyskinesia, is largely associated with long-term use. The FDA recommends limiting metoclopramide treatment to a maximum of 12 weeks due to these risks. Studies show that older adults and individuals with diabetes are more susceptible to TD. Case reports for single dose side effects are (with exception) particularly regarding IM/IV, not oral, doses. In context, this should be considered as well when evaluating the overall risk if you are concerned about it. The reality is that a single, high dose or even the regular, normal doses for the 48-hour Protocol then 3x dose in the SN protocols are not very likely to yield any truly adverse effects from this medication.

About that Scary Black Box Warning: Prior to 2018, estimates suggested there were around 1,000 claims filed from 2005 to 2010, with many involving patients alleging they developed TD after long-term use. The black-box warning for Reglan that came out in 2009 was largely a response to those lawsuits about tardive dyskinesia. It was designed to make sure doctors and patients are aware of the risks involved. While it's super important for safety, it can also make people think that metoclopramide is way more dangerous than it actually is. In reality, for short periods the risks are outstandingly low (even at a 30mg stat dosing, which is anywhere from 2-3x higher than the prescribed clinical use, as discussed above). It's just one of those situations where the warning, to mitigate liability for the manufacturer, can create a bit of unnecessary fear around the medication.

What do Studies About it Show?: A retrospective study from the UK reported that out of 15.9 million prescriptions, only 455 cases of dystonia and 4 cases of tardive dyskinesia were documented (70% were female), indicating a very low incidence relative to the extensive use of the drug. That is about 1 in 34,966. Other studies have side effects way higher suggesting about 1:500 but note this is for any adverse reaction (headache, diarrhea, fatigue, etc). To put this in context for SN, SN itself can and does cause headache, fatigue, and so identifying the difference in what is caused by Metoclopramide over the SN itself is somewhat impossible. Again, given the timing this would be taken before the SN, it is very unlikely any slight chance of a side effect would impair the ability to complete this method.

Perspective on Number of Prescriptions vs Serious Side Effects: Between 2013-2018, ~1.8 million prescriptions were given for metoclopramide annually in the United States alone. In 2018, there were significant legal settlements involving metoclopramide, including around 1,700 cases, bringing a lot of public concern over side effects and their associated risks due to the visibility of the lawsuits. This caused a dip in the annual prescriptions, followed by a dip in 2020; however, by 2022 the annual prescription number increased to ~1.3 million. These lawsuits have primarily involved claims of tardive dyskinesia and other neurological effects, which skewed public perception of the drug's safety. Even if every single one of those cases had definitive proof of this side effect (and let's assume they do), taken contextually for the millions of prescriptions given, we can see just how exceedingly rare it is. If more people truly experienced this, we would have seen significantly more litigants especially in America which is notoriously 'sue happy'.

Let's compare this a little bit with another popular AE for SN Protocols: Domperidone (Motilium). This is going to be a very short discussion just to add a little context and I encourage anyone to do their own additional research, here I am just going to make some broad stroke considerations to hopefully make the point quickly. Like metoclopramide, domperidone is a dopamine D2 receptor antagonist and prokinetic. It is banned in the United States due to risk of cardiac events for general use*, yet remains available in many other countries (UK, Canada, EU, elsewhere). It remains available in the United States as a medication under expanded access for gastrointestinal mobility However, it is also important to remember this: Domperidone was never approved in the US for general use to begin with anyways. Studies indicated that *Domperidone could increase the risk of serious heart issues, including arrhythmias and sudden cardiac arrest, especially in higher doses or in patients with preexisting heart conditions. In 2004, the FDA issued a warning about the potential cardiac risks associated with Domperidone for women taking it for milk production. In 2014, it was formally prohibited from being sold in the U.S., primarily due to these safety concerns particularly among cancer patients who had been prescribed it for nausea and vomiting. Does this mean domperidone is severely dangerous and is going to cause this? Perhaps if you have heart issues. Or are a cancer patient. Or maybe a breast-feeding mother. Even then, it is just an increased risk, not a categorical reaction you will experience. Its ban in the U.S. was primarily due to concerns about serious cardiac risks, especially when compared to its relatively limited use. Meaning it was easier to ban a drug that did not even have general approval for use anyways than spend time, money, and research into its safety than to keep it on the market in America.

Ultimately, in weighing the evidence, it appears that while there are risks associated with metoclopramide, particularly with long-term use, the actual incidence of serious side effects remains relatively low. I may not have covered every single concern around this but tried to take a birds-eye view on this discussion to help set aside the concerns. Keep in mind that the usage of this medication for these protocols is outstandingly brief (further reduced for the Stat Protocol) so the likelihood of them happening in the timeframe before using SN is already outstandingly low. Given the usage in an SN protocol is brief, not outrageously above the 'normal' therapeutic dose, lack of time for side effects to even materialize, it absolutely is a 'safe' addition to the protocol and users should not be concerned around its limited usage here. The lawsuits and subsequent black-box warnings have contributed to a heightened perception of risk, which do not fully align with the clinical realities and millions upon millions of users and doses taken over the decades it has been used.

Hopefully this puts some ease and comfort around the usage of metoclopramide for anyone who had concern around it now that we are a little bit more armed with the facts and about this medication.
A safe choice
 
G

glassbottom

Member
Nov 18, 2024
29
I am taking 150 mg Zoloft. I will take a test dose tomorrow of domperidone. I need to test it anyway due to my source of a pharma retailer abroad. I wonder if anyone here has has had to resort to getting the anti emetic this way?
Hi. How did your test go? I'm on a low dose of Zoloft and have Meto on the way, and this thread is making me nervous, so am interested to hear.
 

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