Domperidone

# Domperidone ## Overview - **Classification**: Dopamine antagonist, antiemetic, prokinetic. - **Mechanism**: Blocks D2 dopamine receptors in the chemoreceptor trigger zone (CTZ) and peripherally in the gastrointestinal tract, promoting gastric emptying. ## Primary Indications 1. **Nausea & Vomiting** - Symptomatic relief of nausea and vomiting, including drug-induced. 2. **Gastroparesis** - Management of chronic or severe gastroparesis (e.g., diabetic gastroparesis). ## Adult Dosing ### Standard Dosing **Nausea & Vomiting / Gastroparesis** - **Dose**: **10 mg** - **Frequency**: Up to three times daily (TID) - **Route**: Oral - **Maximum Dose**: **30 mg/day** - **Duration**: Use lowest effective dose for shortest duration; typically <7 days for acute N/V. ### Dose Adjustments - **Renal Impairment**: - CrCl 30-60 mL/min: Reduce frequency to once or twice daily. - CrCl < 30 mL/min: Reduce frequency to once or twice daily (max 20 mg/day) or consider alternative. - **Hepatic Impairment**: - Moderate (Child-Pugh B): Use with caution; monitor closely. - Severe (Child-Pugh C): **Contraindicated**. - **Elderly Patients**: Use with caution due to increased risk of cardiac adverse events. Start with lower doses (e.g., **10 mg** BID) and monitor cardiac status. ## Pediatric Dosing **⚠️ Note**: Domperidone is generally **not recommended** for routine pediatric use due to cardiac risks. Use only under strict specialist guidance when benefits outweigh risks and no safer alternatives exist. Maximum duration of treatment should be as short as possible. ### Neonates (0-28 days) - **Use is generally contraindicated or strongly discouraged.** - If used under *exceptional* specialist guidance: - **Dose**: **0.25 mg/kg/dose** - **Frequency**: Up to three times daily (TID) - **Maximum**: **0.75 mg/kg/day** or **30 mg/day**, whichever is lower. - **Special Notes**: Closely monitor for cardiac adverse effects. Oral suspension preferred. ### Infants (1-12 months) - **Use is generally contraindicated or strongly discouraged.** - If used under *exceptional* specialist guidance: - **Dose**: **0.25 mg/kg/dose** - **Frequency**: Up to three times daily (TID) - **Maximum**: **0.75 mg/kg/day** or **30 mg/day**, whichever is lower. - **Special Notes**: Closely monitor for cardiac adverse effects. Oral suspension preferred. ### Children (1-12 years) - **Use is generally contraindicated or strongly discouraged.** - If used under *exceptional* specialist guidance: - **Dose**: **0.25 mg/kg/dose** - **Frequency**: Up to three times daily (TID) - **Maximum**: **0.75 mg/kg/day** or **30 mg/day**, whichever is lower. - **Special Notes**: Closely monitor for cardiac adverse effects. Oral suspension or tablets. ### Adolescents (13-18 years) - **Dose**: Adult dosing guidelines apply, typically **10 mg** TID. - **Maximum**: **30 mg/day** - **Special Notes**: Apply same cardiac risk considerations as adults. ## Safety Information ### Contraindications - **Absolute**: Known QT interval prolongation or significant electrolyte disturbances. - **Absolute**: Pre-existing cardiac disease (e.g., heart failure, bradycardia, recent MI). - **Absolute**: Moderate to severe hepatic impairment (Child-Pugh B or C). - **Absolute**: Concurrent use of strong CYP3A4 inhibitors (e.g., ketoconazole, erythromycin). - **Absolute**: Concurrent use of other QT-prolonging drugs. - **Absolute**: GI hemorrhage, mechanical obstruction, or perforation. - **Absolute**: Prolactin-releasing pituitary tumor (prolactinoma). - **Absolute**: Hypersensitivity to domperidone. ### Common Adverse Effects - **Common (1-10%)**: Headache, dry mouth. - **Less Common**: Abdominal cramps, diarrhea, skin rash, pruritus. - **Hormonal**: Hyperprolactinemia (galactorrhea, gynecomastia, amenorrhea, decreased libido). - **Serious but Rare**: QT prolongation, Torsades de Pointes, sudden cardiac death. - **Serious but Rare**: Extrapyramidal symptoms (more common in children or higher doses). ### Key Drug Interactions - **Strong CYP3A4 Inhibitors**: (e.g., ketoconazole, erythromycin, clarithromycin, ritonavir) - **Contraindicated** due to increased domperidone levels and cardiac risk. - **QT-prolonging Drugs**: (e.g., antiarrhythmics, some antipsychotics, some antidepressants) - **Contraindicated** due to additive cardiac risk. - **Dopamine Agonists**: (e.g., bromocriptine, cabergoline) - Domperidone may antagonize their effects. - **Antacids/H2 Blockers/PPIs**: May decrease domperidone absorption; separate administration by >30 mins. ## Monitoring & Follow-up - **Before Treatment**: - Baseline ECG (especially in patients with cardiac risk factors, elderly, or those on interacting drugs). - Assess renal and hepatic function. - Check serum electrolytes (potassium, magnesium) if risk factors present. - **During Treatment**: - Monitor for signs/symptoms of cardiac arrhythmia (palpitations, syncope). - Re-evaluate need for treatment regularly; use lowest effective dose for shortest duration. - For chronic use, consider periodic ECGs and electrolyte monitoring. - **Clinical Signs**: Watch for dizziness, fainting, breast pain/discharge, menstrual irregularities. ## Clinical Pearls - 💡 **Cardiac Risk**: Domperidone is associated with dose-dependent QT prolongation and increased risk of serious ventricular arrhythmias. - 💡 **Lowest Dose, Shortest Duration**: Always use the **lowest effective dose** for the **shortest possible duration**, especially for nausea/vomiting. Do not exceed **30 mg/day**. - 💡 **Avoid Concomitant Risks**: Do not use with strong CYP3A4 inhibitors or other QT-prolonging drugs. - 💡 **Administration**: Take domperidone 15-30 minutes before meals for optimal absorption and prokinetic effect. - 💡 **Patient Counseling**: Instruct patients to report palpitations, dizziness, or fainting immediately. Discontinue if these symptoms occur. > **⚠️ Important**: This information is for educational purposes only. Always consult current prescribing information, local guidelines, and clinical judgment before prescribing.