September 1, 2023

NFL’s 2023 pre-season has come to a close. The regular season starts next week! The fate of many players has been decided. Some made it as a starter. Some secured spots as backups. Others simply were cut or traded! In this installment of UH EMS Institute’s Pharmacy Phriday, we focus on Reglan, back-up to our popular starter Zofran for nausea and vomiting.  

Reglan is an antiemetic (though in a different class than that of Zofran) often used in the treatment of gastric reflux and nausea/vomiting. The medication enhances the effects of the neurotransmitter acetylcholine (ACH) on the upper GI tract, which causes increased gastric motility and emptying of the stomach. In addition, it is a dopamine antagonist (blocks dopamine receptors). Dopamine is one of the neurotransmitters released by GI irritation that can cause nausea and vomiting, and blocking the receptor sites will reduce the symptom or complaint.

Dopamine also plays other roles in the brain, controlling motor and cognitive functions, to name a few. Reglan’s effect in blocking dopamine can affect these other functions, causing altered levels of consciousness, impaired mental and physical abilities, and extrapyramidal symptoms (EPS). EPS symptoms are involuntary muscle movements, often around the face. 

Any time these mentioned conditions already exist or a depressant has caused similar symptoms, they should be considered as contraindications to Reglan’s use. Another contraindication to Reglan’s use is related to the medication’s actions within the body. Due to increased GI motility, it is contraindicated when a patient is suspected of having a GI bleed, obstruction, or perforation. Still, another contraindication is a history of epilepsy due to Reglan’s effect on lowering the seizure threshold, that can result in longer and more frequent seizures for the patient. 

A final contraindication under the UH protocols includes the presence of QT prolongation greater than 500 ms (2.5 large EKG boxes) if noted on the patient’s EKG. This is a rare complication, but if an ECG has been completed and the QT interval is noted as prolonged, the medication should be withheld. Refer back to our review of Zofran in week 2 of the 2023 Pharmacy Phriday series for further information on this topic.

Of all the side effects of Reglan, the most concerning is the extrapyramidal reactions that are more likely to occur in diabetics, children, seniors, and those already taking antipsychotic medications. In cases where EPS does occur, the provider is directed to administer Benadryl. 

The dosing of Reglan under the UH protocols is 10 mg given IV and should be given as a slow push over 2 minutes. It is a fast-acting medication with an onset of about 1-3 minutes via the IV route and has a duration of 1-3 hours. There is no repeat dose recommended. It is a medication only given by the paramedic provider and only to an adult patient. Pediatric dosing is not recommended in the prehospital setting.

It is worth noting to remind all our providers that nausea and vomiting remain a common complaint in emergency medicine, and it is good practice to treat patients early. It does not serve the patient or the crew well to wait until the patient begins vomiting before treatment!

Until next week, STAY SAFE!

Sincerely,



The UH EMS-I Team

University Hospitals