How to treat hiccups?

Consider trying baclofen or gabapentin first for most patients. These seem to be better tolerated, but monitor for sedation.
Mahitab Hany, BS Pharm, PGDipClinPharm, PGDipClinNutrition

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.

SUGGESTED APPROACH TO MANAGE HICCUPS
  • 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

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