Paediatric population:
Clopram is indicated in children (1 – 18 years) for:

• Prevention of delayed chemotherapy induced nausea and vomiting (CINV) as a second line option.
• Treatment of established post‐operative nausea and vomiting (PONV) as a second line option. 

For other indications, the use in the paediatric population is not recommended.

Adult population:
Clopram is indicated in adults for:

• Prevention of post‐operative nausea and vomiting (PONV).
• Symptomatic treatment of nausea and vomiting, including acute migraine induced nausea and vomiting.
• Prevention of radiotherapy induced nausea and vomiting (RINV).

The solution can be administered intravenously or intramuscularly.

Intravenous doses should be administered as a slow bolus (at least over 3 minutes).

All indications (paediatric patients aged 1‐18 years)
The recommended dose is 0.1 to 0.15 mg/kg body weight, repeated up to three times daily by intravenous route. The maximum dose in 24 hours is 0.5 mg/kg body weight.

A minimal interval of 6 hours between two administrations is to be respected, even in case of vomiting or rejection of the dose (see section 4.4). 

Dosing table 

Age	Body Weight	Dose	Frequency
1‐3 years	10‐14kg	1 mg	Up to 3 times daily
3‐5 years	15‐19 kg	2 mg	Up to 3 times daily
5‐9 years	20‐29 kg	2.5 mg	Up to 3 times daily
9‐18 years	30‐60 kg	5 mg	Up to 3 times daily
15‐18 years	Over 60 kg	10 mg	Up to 3 times daily

The maximum treatment duration is 48 hours for treatment of established post‐operative nausea and vomiting (PONV).

The maximum treatment duration is 5 days for prevention of delayed chemotherapy induced nausea and vomiting (CINV).

All indications (adult patients)
For prevention of PONV a single dose of 10mg is recommended. For the symptomatic treatment of nausea and vomiting, including acute migraine induced nausea and vomiting and for the prevention of radiotherapy induced nausea and vomiting (RINV): the recommended single dose is 10 mg, repeated up to three times daily. 

The maximum recommended daily dose is 30 mg or 0.5mg/kg body weight.

The injectable treatment duration should be as short as possible and transfer to oral or rectal treatment should be made as soon as possible.

The maximum recommended treatment duration is 5 days.

Special population
Elderly
In elderly patients a dose reduction should be considered, based on renal and hepatic function and overall frailty.

Renal impairment
In patients with end stage renal disease (Creatinine clearance ≤ 15 ml/min), the daily dose should be reduced by 75%.

In patients with moderate to severe renal impairment (Creatinine clearance 15‐60 ml/min), the dose should be reduced by 50% (see section 5.2).

Hepatic impairment
In patients with severe hepatic impairment, the dose should be reduced by 50% (see section 5.2).

Paediatric population
Metoclopramide is contraindicated in children aged less than 1 year (see section 4.3). 

- Hypersensitivity to the active substance or to any of the excipients listed in section 6.1. - Gastrointestinal haemorrhage, mechanical obstruction or gastro‐intestinal perforation for which the stimulation of gastrointestinal motility constitutes a risk. - Confirmed or suspected phaeochromocytoma, due to the risk of severe hypertension episodes. - History of neuroleptic or metoclopramide‐induced tardive dyskinesia. - Epilepsy (increased crises frequency and intensity). - Parkinson's disease. - Combination with levodopa or dopaminergic agonists (see section 4.5). - Known history of methaemoglobinaemia with metoclopramide or of NADH cytochrome‐b5 deficiency. - Use in children less than 1 year of age due to an increased risk of extrapyramidal disorders (see section 4.4).

Neurological Disorders
Extrapyramidal disorders may occur, particularly in children and young adults, and/or when high doses are used. These reactions occur usually at the beginning of the treatment and can occur after a single administration. Metoclopramide should be discontinued immediately in the event of extrapyramidal symptoms. These effects are generally completely reversible after treatment discontinuation, but may require a symptomatic treatment (benzodiazepines in children and/or anticholinergic anti‐Parkinsonian medicinal products in adults).

The time interval of at least 6 hours specified in the section 4.2 should be respected between each metoclopramide administration, even in case of vomiting and rejection of the dose, in order to avoid overdose.

Prolonged treatment with metoclopramide may cause tardive dyskinesia, potentially irreversible, especially in the elderly. Treatment should not exceed 3 months because of the risk of tardive dyskinesia (see section 4.8). Treatment must be discontinued if clinical signs of tardive dyskinesia appear.

Neuroleptic malignant syndrome has been reported with metoclopramide in combination with neuroleptics as well as with metoclopramide monotherapy (see section 4.8). Metoclopramide should be discontinued immediately in the event of symptoms of neuroleptic malignant syndrome and appropriate treatment should be initiated.

Special care should be exercised in patients with underlying neurological conditions and in patients being treated with other centrally‐acting drugs (see section 4.3).

Symptoms of Parkinson's disease may also be exacerbated by metoclopramide. 

Methaemoglobinaemia
Methaemoglobinaemia which could be related to NADH cytochrome b5 reductase deficiency has been reported. In such cases, metoclopramide should be immediately and permanently discontinued and appropriate measures initiated (such as treatment with methylene blue).

Cardiac Disorders
There have been reports of serious cardiovascular undesirable effects including cases of circulatory collapse, severe bradycardia, cardiac arrest and QT prolongation following administration of metoclopramide by injection, particularly via the intravenous route (see section 4.8).

Special care should be taken when administering metoclopramide, particularly via the intravenous route to the elderly population, to patients with cardiac conduction disturbances (including QT prolongation), patients with uncorrected electrolyte imbalance, bradycardia and those taking other drugs known to prolong QT interval. 

Intravenous doses should be administered as a slow bolus (at least over 3 minutes) in order to reduce the risk of adverse effects (e.g. hypotension, akathisia). 

Renal and Hepatic Impairment
In patients with renal impairment or with severe hepatic impairment, a dose reduction is recommended (see section 4.2).

Clopram contains sodium and sodium metabisulphite
Clopram contains sodium
Clopram contains 4.4 mg of sodium (salt) in each ampoule.If you are on controlled sodium (salt) diet, please tell your doctor in case your sodium intake needs to be adjusted.

Clopram contains sodium metabisulphite
Clopram contains sodium metabisulphite, which may rarely cause hypersensitivity (severe allergy) reactions and bronchospasm (breathing difficulties).

Contraindicated combination
Levodopa or dopaminergic agonists and metoclopramide have a mutual antagonism (see section 4.3).

Combination to be avoided
Alcohol potentiates the sedative effect of metoclopramide.

Combination to be taken into account
Due to the prokinetic effect of metoclopramide, the absorption of certain drugs may be modified.

Anticholinergics and morphine derivatives
Anticholinergics and morphine derivatives may both have a mutual antagonism with metoclopramide on the digestive tract motility.

Central nervous system depressants (morphine derivatives, anxiolytics, sedative H1 antihistamines, sedative antidepressants, barbiturates, clonidine and related)
Sedative effects of Central Nervous System depressants and metoclopramide are potentiated.

Neuroleptics
Metoclopramide may have an additive effect with other neuroleptics on the occurrence of extrapyramidal disorders. 

Serotonergic drugs
The use of metoclopramide with serotonergic drugs such as SSRIs may increase the risk of serotonin syndrome.

Digoxin
Metoclopramide may decrease digoxin bioavailability. Careful monitoring of digoxin plasma concentration is required.

Cyclosporine
Metoclopramide increases cyclosporine bioavailability (Cmax by 46% and exposure by 22%).

Careful monitoring of cyclosporine plasma concentration is required. The clinical consequence is uncertain.

Mivacurium and suxamethonium
Metoclopramide injection may prolong the duration of neuromuscular block (through inhibition of plasma cholinesterase).

Strong CYP2D6 inhibitors
Metoclopramide exposure levels are increased when co‐administered with strong CYP2D6 inhibitors such as fluoxetine and paroxetine. Although the clinical significance is uncertain, patients should be monitored for adverse reactions.

Pregnancy
A large amount of data on pregnant women (more than 1000 exposed outcomes) indicates no malformative toxicity nor foetotoxicity. Metoclopramide can be used during pregnancy if clinically needed. Due to pharmacological properties (as other neuroleptics), in case of metoclopramide administration at the end of pregnancy, extrapyramidal syndrome in the newborn cannot be excluded. Metoclopramide should be avoided at the end of pregnancy. If metoclopramide is used, neonatal monitoring should be undertaken.

Breastfeeding
Metoclopramide is excreted in breast milk at a low level. Adverse reactions in the breast‐fed baby cannot be excluded. Therefore metoclopramide is not recommended during breastfeeding. Discontinuation of metoclopramide in breastfeeding women should be considered.

Metoclopramide may cause drowsiness, dizziness, dyskinesia and dystonias which could affect the vision and also interfere with the ability to drive and operate machinery.

Adverse reactions listed by System Organ Class. Frequencies are defined using the following convention: very common (≥1/10), common (≥1/100, <1/10), uncommon (≥1/1000, <1/100), rare (≥1/10000, <1/1000), very rare (<1/10000), not known (cannot be estimated from the available data). 

Blood and lymphatic system disorders
Not known	Methaemoglobinaemia, which could be related to NADH cytochrome b5 reductase deficiency, particularly in neonates (see section 4.4) Sulfhaemoglobinaemia, mainly with concomitant administration of high doses of sulfur-releasing medicinal products.
Cardiac disorders
Uncommon	Bradycardia, particularly with intravenous formulation
Not known	Cardiac arrest, occurring shortly after injectable use, and which can be subsequent to bradycardia (see section 4.4); Atrioventricular block, Sinus arrest particularly with intravenous formulation; Electrocardiogram QT prolonged; Torsade de Pointes;
Endocrine disorders*
Uncommon	Amenorrhoea, Hyperprolactinaemia,
Rare	Galactorrhoea
Not known	Gynaecomastia
Gastrointestinal disorders
Common	Diarrhoea
General disorders and administration site conditions
Common	Asthenia
Not Known	Injection site inflammation and local phlebitis
Immune system disorders
Uncommon	Hypersensitivity
Not known	Anaphylactic reaction (including anaphylactic shock) particularly with intravenous formulation
A few cases of rash, urticaria, bronchospasm, especially in patients with a history of asthma.
Nervous system disorders
Very common	Somnolence
Common	Extrapyramidal disorders (particularly in children and young adults and/or when the recommended dose is exceeded, even following administration of a single dose of the drug) (see section 4.4), Parkinsonism, Akathisia
Uncommon	Dystonia, Dyskinesia, Depressed level of consciousness
Rare	Convulsion especially in epileptic patients
Not known	Tardive dyskinesia which may be persistent, during or after prolonged treatment, particularly in elderly patients (see section 4.4), Neuroleptic malignant syndrome (see section 4.4)
Psychiatric disorders
Common	Depression
Uncommon	Hallucination
Rare	Confusional state
Vascular disorder
Common	Hypotension, particularly with intravenous formulation
Not known	Shock, syncope after injectable use. Acute hypertension in patients with phaeochromocytoma (see section 4.3). Transient increase in blood pressure.
Skin disorder
Not known	Skin reactions such as rash, pruritus, angioedema and urticaria
*Endocrine disorders during prolonged treatment in relation with hyperprolactinaemia (amenorrhoea, galactorrhoea, gynaecomastia).

The following reactions, sometimes associated, occur more frequently when high doses are used:

• Extrapyramidal symptoms: acute dystonia and dyskinesia, parkinsonian syndrome, akathisia, even following administration of a single dose of the medicinal product, particularly in children and young adults (see section 4.4).
• Drowsiness, decreased level of consciousness, confusion, hallucination. 

Reporting of suspected adverse reactions
Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via:
• Saudi Arabia
The National Pharmacovigilance Center (NPC)
Fax: + (966‐11) 2057662
Call NPC at: + (966‐11) 2038222, Exts: 2317‐2356‐2340.
SFDA Call Center: 19999
e‐mail: npc.drug@sfda.gov.sa
Website: https://ade.sfda.gov.sa/
• Other GCC States
Please contact the relevant competent authority. 

Symptoms
Extrapyramidal disorders, drowsiness, a decreased level of consciousness, confusion, hallucination and cardio‐respiratory arrest may occur.

Management
In case of extrapyramidal symptoms related or not to overdose, the treatment is only symptomatic (benzodiazepines in children and/or anticholinergic anti‐parkinsonian medicinal products in adults).

A symptomatic treatment and a continuous monitoring of the cardiovascular and respiratory functions should be carried out according to clinical status.

Metoclopramide as a dopamine antagonist stimulates gastric motility and gastric emptying and speeds small intestinal transit time by increasing gastric peristalsis and increasing the resting tone of the gastro oesophageal sphincter.

Renal impairment
The clearance of metoclopramide is reduced by up to 70% in patients with severe renal impairment, while the plasma elimination half‐life is increased (approximately 10 hours for a creatinine clearance of 10‐50 mL/minute and 15 hours for a creatinine clearance <10 mL/minute).

Hepatic impairment
In patients with cirrhosis of the liver, accumulation of metoclopramide has been observed, associated with a 50% reduction in plasma clearance.

No further information other than that which is included in the Summary of Product Characteristics.

• Citric acid anhydrous
• Potassium citrate
• Disodium edatate
• Sodium metabisulphite
• Sodium chloride
• Benzyl alcohol
• Water for injection

Any dilutions of metoclopramide ampoule should be protected from light during infusion.

Degradation is indicated by a yellow discoloration. Such solution must not be used.

3 years.

Do not store above 30°C.

Store in the original package in order to protect prom light.

2 ml type I amber glass ampoules.

Pack size: 5 ampoules.

If only part of an ampoule is used, discard the remaining solution.