Formulary
Domperidone: Uses, Dosing, Side Effects and Indian Brand Names
Domperidone is a peripheral D2 antagonist that does not cross the BBB, providing antiemetic and prokinetic effects without extrapyramidal side effects. It is safer than metoclopramide for CNS side effects but carries a risk of QT prolongation at higher doses.
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Domperidone: Uses, Dosing, Side Effects and Indian Brand Names
Domperidone is a peripheral D2 antagonist that does not cross the BBB, providing antiemetic and prokinetic effects without extrapyramidal side effects. It is safer than metoclopramide for CNS side effects but carries a risk of QT prolongation at higher doses.
NEET PG High-Yield: Domperidone does NOT cross the BBB -- no EPS, no sedation (key differentiator from metoclopramide). It is the antiemetic of choice in Parkinson's disease. Causes hyperprolactinaemia because the pituitary is outside the BBB. QT prolongation is the cardiac safety concern. Metoclopramide crosses the BBB and causes EPS (especially acute dystonia in young females) -- a classic comparator question.
Clinical overview
Domperidone is one of the most commonly used antiemetics and prokinetics in India. Its inability to cross the blood-brain barrier in significant amounts gives it a major safety advantage over metoclopramide -- it does not cause extrapyramidal side effects (acute dystonia, akathisia, tardive dyskinesia) and does not cause sedation. This makes it particularly useful in paediatric patients and in patients with Parkinson's disease who need an antiemetic (dopamine antagonists that cross the BBB would worsen parkinsonism). Domperidone is widely used for functional dyspepsia, gastroparesis (especially diabetic gastroparesis), nausea and vomiting associated with dopamine agonist therapy in Parkinson's disease, and as an adjunct to levodopa therapy. It causes hyperprolactinaemia (prolactin release is inhibited by dopamine in the tuberoinfundibular pathway, and the pituitary is outside the BBB), leading to galactorrhoea and amenorrhoea. This side effect has been therapeutically exploited to promote lactation in breastfeeding mothers (off-label use as a galactagogue). The main safety concern identified in recent years is QT prolongation and risk of sudden cardiac death, particularly at doses >30 mg/day and in patients >60 years. The EMA restricted domperidone to a maximum of 30 mg/day and 7 days duration for acute use, though this restriction is not uniformly enforced in Indian practice.
Pharmacological class
Domperidone belongs to the Peripheral dopamine D2 receptor antagonist (prokinetic and antiemetic) class. Domperidone selectively blocks dopamine D2 receptors in the chemoreceptor trigger zone (CTZ, located in the area postrema OUTSIDE the blood-brain barrier) and in the upper GI tract. In the CTZ, D2 blockade produces an antiemetic effect. In the GI tract, D2 blockade enhances acetylcholine release from the myenteric plexus, increasing gastric motility, accelerating gastric emptying, and improving antroduodenal coordination. Crucially, domperidone does NOT readily cross the blood-brain barrier, so it lacks the central dopamine-blocking effects (extrapyramidal side effects) seen with metoclopramide.
Indian brand names and formulations
Available as: Domstal (Torrent Pharmaceuticals), Vomistop (Cipla), Motilium (Janssen/Johnson & Johnson), Domcet (FDC Limited).
Tablets (10 mg), Oral suspension (5 mg/5 mL), Rectal suppositories (30 mg, 60 mg -- limited availability in India), Fixed-dose combinations with PPIs (Omeprazole + Domperidone as Omez-D, Pantoprazole + Domperidone as Pan-D)
Regulatory status
Domperidone is classified under Schedule H in India under the Drugs and Cosmetics Act, 1940. Schedule H prescription drug. EMA recommendation: maximum 30 mg/day, maximum 7 days for acute nausea/vomiting. Indian regulations are less restrictive but cardiac risk awareness is increasing.
Indications
- Nausea and vomiting (various causes)
- Functional dyspepsia
- Gastroparesis (diabetic, post-surgical)
- Nausea associated with dopamine agonist therapy (Parkinson's disease -- cannot use metoclopramide as it worsens parkinsonism)
- Gastro-oesophageal reflux (adjunct -- improves LES tone and gastric emptying)
- Lactation enhancement (off-label galactagogue)
Dosing
Adults: 10 mg TDS, taken 15-30 minutes before meals (max 30 mg/day per EMA recommendation). Children (>12 years): 10 mg TDS. Children (<12 years): 0.25 mg/kg TDS. Duration: limit to 7 days for acute nausea/vomiting; longer use for gastroparesis under specialist supervision. Galactagogue (off-label): 10 mg TDS for 7-14 days. Avoid in severe hepatic impairment.
Contraindications
- Known QT prolongation or cardiac conduction disorders
- Concurrent use with QT-prolonging drugs (ketoconazole, erythromycin, amiodarone)
- Prolactinoma (D2 blockade increases prolactin)
- GI conditions where stimulation of motility is dangerous (GI perforation, mechanical obstruction, GI haemorrhage)
- Severe hepatic impairment
- Moderate to severe renal impairment (reduce frequency)
Adverse effects
- Hyperprolactinaemia (galactorrhoea, gynaecomastia, amenorrhoea, sexual dysfunction)
- QT prolongation and risk of ventricular arrhythmias (especially >30 mg/day, elderly, cardiac disease)
- Dry mouth
- Headache
- GI cramping and diarrhoea (prokinetic effect)
- NO extrapyramidal effects (does not cross BBB -- key differentiator from metoclopramide)
- NO sedation
Drug interactions
- CYP3A4 inhibitors (ketoconazole, itraconazole, erythromycin, clarithromycin) -- increase domperidone levels AND prolong QT; avoid combination
- QT-prolonging drugs (amiodarone, haloperidol, quinolones) -- additive cardiac risk
- Anticholinergic drugs -- pharmacological antagonism (reduce prokinetic effect)
- Opioids -- domperidone may partially counteract opioid-induced gastroparesis
Pregnancy and lactation
Category C. Limited human data. Animal studies have shown no teratogenicity. Used cautiously in pregnancy when benefit outweighs risk. Generally considered safer than metoclopramide in pregnancy due to lack of CNS effects, but data is insufficient for a definitive safety recommendation. Doxylamine + pyridoxine is first-line for nausea in pregnancy.
Exam-style clinical scenario
A 65-year-old man with Parkinson's disease on levodopa-carbidopa and pramipexole develops persistent nausea and vomiting, likely from his dopamine agonist therapy. Which antiemetic should be used? Answer: Domperidone 10 mg TDS before meals is the antiemetic of choice. It blocks D2 receptors in the CTZ (outside the BBB) without crossing into the brain, so it does NOT worsen parkinsonism. Metoclopramide is CONTRAINDICATED in Parkinson's disease because it crosses the BBB and blocks central D2 receptors, worsening motor symptoms. Check ECG for QT interval before starting domperidone, especially in this age group.
Cost in India
INR 20-50 per strip of 10 tablets (10 mg); oral suspension: INR 30-60; FDC with PPI: INR 40-80
Clinical governance
Author: MedNext Editorial Team. Clinical reviewer: Awaiting clinical review. Jurisdiction: India (Drugs and Cosmetics Act, 1940). Sources: CIMS India, Indian Pharmacopoeia. Publication state: Awaiting clinical review. Correction: Report errors at support@mednext.academy.
Frequently Asked Questions
If domperidone does not cross the BBB, how does it cause hyperprolactinaemia?
The anterior pituitary gland is located outside the blood-brain barrier, in a region with fenestrated capillaries (circumventricular organ). Domperidone reaches the pituitary through the systemic circulation without needing to cross the BBB. By blocking D2 receptors on lactotroph cells (which are tonically inhibited by hypothalamic dopamine), it removes the dopaminergic suppression of prolactin secretion, causing hyperprolactinaemia.
Why does metoclopramide cause EPS but domperidone does not?
Metoclopramide is more lipophilic and readily crosses the blood-brain barrier, where it blocks D2 receptors in the nigrostriatal pathway (causing EPS) and can also enter the mesocortical pathway (causing sedation). Domperidone is more polar (quaternary ammonium structure in its protonated form) and does not significantly penetrate the BBB, so it blocks D2 receptors only in peripheral areas (CTZ, GI tract, pituitary) without affecting the basal ganglia or cortex.
Is domperidone safe as a galactagogue?
Domperidone is widely used off-label to promote lactation by increasing prolactin levels. Studies show modest benefit in increasing breast milk volume. However, the EMA and Health Canada have cautioned about cardiac risk (QT prolongation, sudden cardiac death), especially at doses >30 mg/day. Its use as a galactagogue should be limited to the lowest effective dose (10 mg TDS) for the shortest duration, after non-pharmacological measures have failed, and after a cardiac risk assessment.
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