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

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)
    • Phenytoin 200-300 mg HS PO
    • Gabapentin 300 mg HS PO
    • Carbamazepine 100-200 mg bid PO
    • Clonazepam 0.5-1 mg bid PO
  • Consider SSRIs

• 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!

• 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.

Back to top of page Next page Previous page