A trial of midazolam vs diphenhydramine in prophylaxis of metoclopramide-induced akathisia.

STUDY OBJECTIVE: The study aimed to evaluate the effects of midazolam and diphenhydramine for the prevention of metoclopramide-induced akathisia. METHODS: This randomized, double-blind, and controlled trial aimed to investigate coadministered midazolam vs diphenhydramine in the prophylaxis of metoclopramide-induced akathisia. Patients 18 to 65 years of age who presented to the emergency department with primary or secondary complaints of nausea and/or moderate to severe vascular-type headache were eligible for this study. Patients were randomized to one of the fallowing 3 groups: (1) metoclopramide 10 mg + midazolam 1.5 mg; (2) metoclopramide 10 mg + diphenhydramine 20 mg; (3) metoclopramide 10 mg + placebo. Metoclopramide was administered as a 2-minute bolus infusion. Midazolam, diphenhydramine, and normal saline solution were administered as a 15-minute slow infusion. The whole procedure was observed; and akathisia and sedation scores and vital changes were recorded. RESULTS: There were significant differences among groups with respect to akathisia (P = .016) and sedation (P < .001). The midazolam group showed the lowest mean akathisia score but the highest mean sedation score. Akathisia scores of the diphenhydramine group were not different from placebo. There were significant differences among groups in terms of changes in mean vital findings such as respiration rates, pulse rates, and systolic blood pressures (P < .05). There were no significant difference among groups in terms of changes in mean diastolic blood pressures (P = .09). CONCLUSION: Coadministered midazolam reduced the incidence of akathisia induced by metoclopramide compared to placebo but increased the rate of sedation. No difference was detected from diphenhydramine. Routine coadministered 20 mg diphenhydramine did not prevent metoclopramide-induced akathisia.

Slow infusion metoclopramide does not affect the improvement rate of nausea while reducing akathisia and sedation incidence.

OBJECTIVE: To compare the effects of metoclopramide infusion in emergency department (ED) patients complaining of nausea to determine the changes in its therapeutic effect and prevention of side effects such as akathisia and sedation. METHODS: A prospective, randomised, double blind trial, from 1 March 2007 to 1 May 2008 in the ED of Pamukkale University Faculty of Medicine. Patients with moderate to severe nausea were randomised and divided into two groups: group 1 received 10 mg metoclopramide as a slow intravenous infusion over 15 min plus placebo (SIG); group 2 received 10 mg metoclopramide as an intravenous bolus infusion over 2 min plus placebo (BIG). The whole procedure was observed, and nausea scores, akathisia and vital changes were recorded. RESULTS: 140 patients suffering from moderate to severe nausea in the ED were included in the study. There was no significant difference between the groups in terms of mean nausea scores during follow-up (p=0.97). A significant difference in akathisia incidence was observed between the groups (18 (26.1%) in the BIG and 5 (7%) in the SIG) (p=0.002). There was also a significant difference in sedation incidence between the groups (19 (27.5%) in the BIG and 10 (14.5%) in the SIG) (p=0.05). CONCLUSION: Even though slowing the rate of infusion of metoclopramide does not affect the rate of improvement in nausea, it may be an effective strategy for reducing the incidence of akathisia and sedation in patients with nausea.

Severe metformin intoxication treated with prolonged haemodialyses and plasma exchange.

BACKGROUND: Biguanides pose a significant risk of morbidity, mortality and permanent sequelae secondary to prolonged periods of hypoglycaemia. OBJECTIVES: To investigate the treatment of massive metformin overdose associated with lactic acidosis. CASE REPORT: We present the case of a 30-year-old woman, who attempted to commit suicide by ingesting an 85-g massive metformin overdose associated with severe lactic acidosis, which we treated by performing prolonged haemodialysis with bicarbonate and plasma exchange. CONCLUSION: For the maximum elimination of metformin, extended haemodialysis is required and the treatment of the accompanying metabolic acidosis with bicarbonate is important for the effectiveness of the treatment. Patients benefit much more from the treatment of combined haemodialysis with plasma exchange.