Risk of ischemic stroke may transiently increase during metoclopramide initiation

This article is from NEJM Journal Watch Risk For Ischemic Stroke Might Increase Briefly After Starting Metoclopramide May Briefly Increase Risk of Ischemic Stroke During Metoclopramide Initiation Review by Bruce Soloway, MD Inform patients of risks and other well-known neurological side effects
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Antidopaminergic antipsychotics acting on the central nervous system increase the risk of ischemic stroke, especially in elderly and dementia patients, and the risk is greatest during the first month of use
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Antidopaminergic antiemetics (ADA; such as metoclopramide) that act on the peripheral nervous system and are not antipsychotics are sometimes prescribed to patients for short-term treatment of nausea and vomiting, or for long-term treatment of diabetic gastroparesis
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Do these drugs also increase ischemic stroke risk? In a cross-over case-control study using the French National Health Insurance database, investigators identified 2,800 first-time ischemic strokes who had started ADA (ie, metoclopramide, domperidone, or metoprape) within the previous 70 days.
metopimazine, the latter two are not widely available in the United States)
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They compared ADA use rates in the 14 days before the onset of stroke and earlier reference periods, and adjusted for changes in ADA use rates over time in a matched population without stroke
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In the adjusted analysis, patients were significantly more likely to have used ADA in the 14 days prior to stroke than in the earlier reference period (odds ratio, 3.
12)
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The odds ratio for metoclopramide alone was 3.
53
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Similar results were obtained in analyses stratified by age, sex, and dementia status
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Commentary Given the methodological limitations of this study, the absolute increase in stroke risk during the initiation of metoclopramide is unknown, but may be small
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This risk, as well as other potential adverse effects (eg, somnolence and dyskinesia), should be explained to patients when they first receive ADA
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Reviewed article Bénard-Laribière A et al.
Risk of first ischaemic stroke and use of antidopaminergic antiemetics: Nationwide case-time-control study.
BMJ 2022 Mar 23; 376:e066192.
(https://doi.
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