Metoclopramide use in upper GI bleeding stalled by ‘startling’ lack of published trials
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Key takeaways:
- Evidence for metoclopramide use in upper GI bleeding is very low, with few published trial data.
- Existing data have not been published beyond the abstract form.
VANCOUVER, British Columbia — Metoclopramide may be effective for patients with upper gastrointestinal bleeding, but a scarcity of published trial data hinders its use, according to a presentation at the ACG Annual Scientific Meeting.
Although commonly used to boost endoscopic visualization in patients with upper GI bleeding, metoclopramide lacks the body of evidence and guideline-backing of its fellow prokinetic, erythromycin. However, as metoclopramide is less costly than erythromycin and administered via injection rather than infusion, it may still offer advantages in patient care.
“In clinical practice, erythromycin has had guideline endorsement for about a decade now because there is a robust body of evidence for its use in this setting,” Faisal S. Ali, MD, study author and fellow at the McGovern Medical School at UTHealth Houston, told Healio. “Unfortunately, metoclopramide doesn’t have the same benefit as erythromycin when it comes to evidence base. Erythromycin has published trials, with meta-analyses done that have shown a signal in favor of improved visualization when they do endoscopy for it. Unfortunately for metoclopramide, that is not the case.”
To determine whether there may be sufficient evidence for the use of metoclopramide in upper GI bleeding, Ali and colleagues conducted a systematic review of Medline and Embase to identify studies comparing metoclopramide against control groups. The researchers also performed a meta-analysis of endoscopic visualization scores.
According to study results, the researchers identified six abstracts of randomized controlled trials, which enrolled 236 patients in the metoclopramide group and 214 in the control group. However, only two studies noted the dose and protocol of metoclopramide use. Among the six abstracts, researchers also found multiple studied endpoints, including mean number of RBC transfusion, second look endoscopy, retained clots in the stomach, residual blood in the stomach, endoscopic visualization score and duration of hospitalization.
Ali and colleagues also observed that four of the abstracts used the modified Avgerinos score to quantify endoscopic visualization. Of these, one abstract reported improved endoscopic visualization in the metoclopramide group but it was not statistically significant; a second abstract reported no difference in visualization or statistical significance. However, the two remaining abstracts noted improved endoscopic visualization and statistical significance for metoclopramide.
In their comparative meta-analysis, the researchers found that metoclopramide use was linked to improved endoscopic visualization scores in the antrum (standardized mean difference = 0.33; 95% CI, 0.11-0.55; I2 = 0%), body (SMD = 0.3; 95% CI, 0.03-0.58; I2 = 36.24%), fundus (SMD = 0.94; 95% CI, 0.08-1.8; I2 = 92.93%) and total modified Avgerinos score (SMD = 0.42; 95% CI, 0.2-0.64; I2 = 0%) compared with the control group.
“From an evidence standpoint, the thing that stands out to me is, with the six trials, we found that none of them are published beyond an abstract form — that is just startling to me,” Ali told Healio. “I don’t think this is due to failure of effort to publish by the investigators who did the trials. They must have tried to submit it somewhere; it just never got accepted. We need to address the fact that, if we are to prioritize an observational nonrandomized study over a randomized trial for publication, just because it’s hot topic, then that speaks to our compass.”
Ali added: “In pulling these [abstracts] together, we did have a signal in favor of metoclopramide use in endoscopic visualization of the fundus, body, antrum and total endoscopic visualization score. That is a pretty consistent signal, even though it is not based on a robust body of evidence, it is consistent in all domains; that reinforces the fact that we need these trials to be published.”
Once these trials are published in their entirety, Ali noted that researchers may be able to use the data to determine “the actual certainty of the evidence” for metoclopramide in patients with upper GI bleeding.
“Right now, the certainty of the evidence [for metoclopramide] is very low,” he told Healio. “And it may go from very low to low once the trial data are published. There is limited reporting, there is no standardization, things are not published all the way. If we address these problems in a manner that allows a meta-analysis of all data from all six studies, I have a feeling that we will possibly see a signal in favor of metoclopramide use. But if not, at least we will have evidence to the point that the next set of guidelines can comment on its use by clinicians.”
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Reymunde Duran DA, et al. Metoclopramide use in the setting of upper gastrointestinal bleed: An updated meta-analysis. Presented at: ACG Annual Scientific Meeting; Oct. 20-25, 2023; Vancouver, British Columbia (hybrid meeting).
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