Extrapyramidal symptoms and effectiveness of continuous vs bolus intravenous metoclopramide: A systematic review and meta-analysis.

OBJECTIVE: Metoclopramide is widely used to treat nausea, vomiting, and headache. However, it may cause extrapyramidal symptoms (EPS) such as akathisia. Continuous intravenous (IV) infusion has been proposed as a safer alternative to bolus injection. This study aimed to compare the risk of EPS and effectiveness between continuous and bolus IV metoclopramide administration. METHODS: We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing continuous vs. bolus IV administration of metoclopramide. Databases searched included CENTRAL, MEDLINE, Embase, CINAHL, ClinicalTrials.gov, and ICTRP (inception to January 2025). The primary analysis was restricted to trials conducted in the emergency department (ED), with secondary analyses including all clinical settings. Primary outcome was the occurrence of EPS. Secondary outcomes included nausea severity; headache severity; occurrence of akathisia. Pooled estimates were calculated using random-effects models (standardized mean differences [SMDs], risk ratios [RRs]). RESULTS: Among 5878 randomized controlled trials screened, seven trials (924 patients) were included in the meta-analysis. Across five ED trials, continuous infusion was associated with a lower risk of EPS (RR: 0.34; 95% CI: 0.15 to 0.79; I2 = 75.1%), with EPS outcomes in ED trials being defined as akathisia. Two trials assessed nausea severity (SMD: 0.10; 95% CI: -0.13 to 0.32; I2 = 0%). One trial assessed headache severity (SMD 0.17; 95% CI: -0.18 to 0.53). CONCLUSION: In the emergency department, continuous intravenous metoclopramide was associated with a lower risk of EPS without clear differences in symptom control, suggesting that continuous infusion may be a reasonable approach in clinical practice.