Hiccups

KEYPOINTS

  • Hiccups (singulus) are repeated involuntary contractions of the diaphragm and respiratory muscles
  • There are close to 100 different causes of hiccups - causes may be natural or drug-induced
  • Gastrointestinal causes are the most common cause of hiccups
  • Hiccups can be extremely distressing and can lead to fatigue and sleep disturbance
  • Treatment options include both pharmacologic and non-pharmacologic approaches

ASSESSMENT

(see Foreword)

  • A good clinical assessment is important to try and identify the underlying cause of the hiccups. Finding the cause (if possible) can often help direct treatment

Causes of Hiccups

  • Gastric distension or gastro-oesophageal reflux disease (most common)
    • Overload
    • Obstruction
    • Gastritis or oesophagitis
  • Irritation of the diaphragm
    • Hepatic and other tumours
    • Infection or inflammation
    • Ascites
  • Other problems involving the thorax or abdomen
    • Pneumonia
    • Pericarditis
  • Pancreatitis
  • Medications
    • e.g. corticosteroids
  • Metabolic problems
    • Renal failure/uraemia
    • Hyponatremia
  • Intracranial disease
    • Tumours - especially brain stem lesions
  • Infection
  • Idiopathic (unknown cause)

MANAGEMENT

  • Consider treatment of the underlying cause if one is identifiable
    • Remove offending pharmacologic agents
    • Correct imbalances/infections if possible
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Consider if patient is well enough to benefit
  • If due to gastric distension
    • Decrease gastric distension by encouraging smaller more frequent meals
    • Use a prokinetic drug such as metoclopramide 10 mg qid PO or domperidone 10 mg qid PO
    • Simethicone/dimethicone containing agents 5 mls qid and prn PO may help to decrease gas and distension
  • If due to gastro-oesophageal reflux provide treatment such as omeprazole 20 mg once a day PO
  • If a cause can not be identified or corrected then general measures should be used
  • General non-pharmacological measures (many different measures have been suggested)
    • Pharyngeal stimulation
      • Eating 1-2 teaspoons of sugar or crushed ice
      • Lightly rubbing the midline of the soft palate for 1 minute
      • Long slow slips of water
    • Breath holding or rebreathing into a bag
    • Passage of a naso-gastric tube
    • Massage of external auditory canal
  • General pharmacological measures (many have been tried; little evidence of efficacy exists)
    • Baclofen 5-10 mg tid PO has been shown to be effective in intractable hiccups
    • Chlorpromazine 10-25-50 mg qid PO
    • Nifedipine 10-20 mg bid to tid PO
    • Haloperidol 1-5 mg q4-12h PO/SC/IV
    • Anticonvulsants (starting doses)
    • Consider SSRIs
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  • Metoclopramide 0.1 to 0.2 mg/kg/dose q6h PO/SC/IV
  • Chlorpromazine 0.5-1 mg kg/dose q4-6h PO or q6-8h IV
  • Haloperidol 0.05-0.15 mg/kg/24h in divided doses bid or tid PO/SC/IV
  • Phenytoin 4-8 mg/kg/24hrs in divided doses bid or tid PO
  • Gabapentin 10-30 mg/kg/24h in divided doses tid PO
  • Carbamazepine
    • Less than 6 years: 10-20 mg/kg/24h in divided doses bid or tid PO
    • Over 6 years: 100 mg bid PO

PITFALLS/CONCERNS

  • The same agents that are used to treat hiccups may also cause them!
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  • Although sometimes used to treat hiccups some reports suggest that benzodiazepines may cause or exacerbate hiccups
  • Metoclopramide and haloperidol (and other neuroleptics) can cause extra pyramidal reactions in children and can be used in combination with diphenhydramine to reduce likelihood of this

PALLIATIVE TIPS

  • Gastric distension and gastro-oesophageal reflux disease are the most common cause of hiccups and a trial of treatments as outlined above should be considered
  • Combinations of agents is sometimes required for intractable hiccups

SOURCES/REFERENCES

  1. Sanjay S, Manoharan B, Arun KN, Sundar S. Baclofen in the treatment of intractable hiccups. J Assoc Physicians India 2002;50:1312-1313.
  2. Smith HS, Busracamwongs A. Management of hiccups in the palliative care population. Am J Hosp Palliat Care 2003;20(2):149-154. http://www.ncbi.nlm.nih.gov/pubmed/12693648
  3. Thompson DF, Landry JP. Drug induced hiccups. Ann Pharmacother 1997;31(3):367-369. http://www.ncbi.nlm.nih.gov/pubmed/9066948
  4. Twycross R. Baclofen for hiccups. Am J Hosp Palliat Care 2003;20(4):262; author reply 262.
  5. Twycross R. Palliative care formulary. 2nd ed. Oxford:Radcliffe Publishing; 2002.

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