AS A PHARMACIST, you will hear new thinking about how to treat hiccups...!
Short-term bouts of hiccups are annoying, but not harmful. And home remedies, such as gargling ice water, swallowing a teaspoon of sugar, or even drinking pickle juice and may do the trick. But keep in mind, persistent hiccups that last for more than two days may be a sign of an underlying problem. Evaluate patients for common causes. Look for GI problems such as a peptic ulcer or abdominal abscess, CNS issues including meningitis or brain tumor or medications such as corticosteroids or dopaminergic agents.
Consider treating if persistent hiccups are causing distress. But be aware there's limited evidence of efficacy for any therapy. We're used to using chlorpromazine or other options such as haloperidol or metoclopramide. Chlorpromazine is the only drug approved for intractable hiccups (see dosage in Table 1). But these medications are linked to QT prolongation and movement disorders.
Instead, consider trying baclofen or gabapentin first for most patients. These seem to be better tolerated, but monitor for sedation. Try a medication for up to 7 to 10 days if needed, then switch to another medication if hiccups persist.
- Use nonpharmacologic measures, particularly those which have been helpful in the past.
- Attempt simethicone, domperidone, or metoclopramide, or a proton pump inhibitor.
- Prescribe baclofen if renal function is reasonable.
- Add gabapentin.
- Attempt chlorpromazine or haloperidol if hiccups persist (or attempt at Step 3 if renal function is decreased).
- Consider nifedipine, valproic acid, dexamethasone, or sertraline.
- Add midazolam infusion 10-60 mg/day.
| Table (1). Pharmacological therapy of Hiccup | ||
|---|---|---|
| Recommended Medication | Typical dose/day | Common or important side effects and safety concerns |
| First line | ||
| Baclofen | 5–20 mg/day 3 times daily | Sedation, renal impairment (in elderly patients with pre-existing disease) |
| Gabapentin | 300–600 mg/day 3 times daily | Sedation, visual disturbance, clumsiness/unsteadiness |
| Pregabalin | 75–150 mg/day twice daily | Sedation (less often than gabapentin), breathing difficulties |
| Second line | ||
| Metoclopramide | 10 mg 3 times daily | Neurological and other side effects less often than chlorpromazine |
| Domperidone | 10 mg 3 times daily | Neurological side effects less often than metoclopramide Hyperprolactinemia, long QT syndrome/cardiac arrhythmia |
| Third line | ||
| Chlorpromazine | 25 mg 4 times a day, increasing to 50 mg 4 times a day if needed | Sedation, postural hypotension (common with IV dosing), neurological and other side effects |
| Other choices | ||
| Carbamazepine | 100–300 mg 3 to 4 times daily | Blurred vision, neurological and mood disturbance |
| Valproate | Dose titration to 20 mg/kg/day | Weight gain, liver failure, neurological and mood disturbance |
| Phenytoin | 100 mg 3 times daily | Weight gain, coarse facies, neurological and mood disturbance |
| Nifedipine | 60–180 mg/day | Hypotension, headache, peripheral oedema, respiratory effects |
| Amitriptylline | 25–100 mg once at night | Sedation, dry mouth, constipation, cardiac arrhythmia in overdose consider if visceral hypersensitivity appears to be causative factor |
REFERENCES
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Steger M, Schneemann M, Fox M. Systemic review: the pathogenesis and pharmacological treatment of hiccups. Aliment Pharmacol Ther. 2015 Nov;42(9):1037-50. Available at: https://onlinelibrary.wiley.com/doi/10.1111/apt.13374
Woelk, C.J. (2011). Managing hiccups. Canadian Family Physician, [online] 57(6), pp.672–675. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3114667/#b4-0570672
Moretto EN, Wee B, Wiffen PJ, Murchison AG. Interventions for treating persistent and intractable hiccups in adults. Cochrane Database Syst Rev. 2013 Jan 31;2013(1):CD008768. Available at: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD008768.pub2/full
Nausheen, F., Mohsin, H. and Lakhan, S.E. (2016). Neurotransmitters in hiccups. SpringerPlus, 5(1). Available at: https://springerplus.springeropen.com/articles/10.1186/s40064-016-3034-3