From the Guidelines
Chlorpromazine is the most effective treatment for intractable hiccups, and it should be started at a dose of 25-50 mg orally or intramuscularly every 6 hours as needed 1. The best treatment for intractable hiccups typically involves a combination of medications and non-pharmacological approaches.
Medication Treatment
- Chlorpromazine, a phenothiazine, can be used to treat nausea/vomiting and intractable hiccups, as mentioned in the study 1.
- The dose of chlorpromazine can be adjusted based on the patient's response, but it is essential to monitor for potential side effects, such as QTc prolongation, which can be a concern with antipsychotic medications 1.
Non-Pharmacological Methods
Some non-pharmacological methods can be attempted first or alongside medication, including:
- Breath-holding for 10-20 seconds
- Drinking water quickly from the opposite side of a glass
- Swallowing granulated sugar
- Stimulating the vagus nerve by gently pulling on the tongue If these methods fail, it is crucial to consult a physician for further evaluation, as persistent hiccups may indicate an underlying medical condition.
Mechanism of Action
Chlorpromazine works by suppressing the hiccup reflex arc in the central nervous system, which can help alleviate intractable hiccups 1. It is essential to prioritize the patient's safety and monitor for potential side effects when using chlorpromazine or any other medication to treat intractable hiccups.
From the FDA Drug Label
Intractable Hiccups– 25 mg to 50 mg t.i.d. or q.i.d. If symptoms persist for 2 to 3 days, parenteral therapy is indicated. If symptoms persist for 2-3 days after trial with oral therapy, give 25 to 50 mg (1-2 mL) IM. Should symptoms persist, use slow IV infusion with patient flat in bed: 25 to 50 mg (1-2 mL) in 500 to 1000 mL of saline.
The best treatment for intractable hiccups is chlorpromazine. The recommended dosage is:
- Oral: 25 mg to 50 mg t.i.d. or q.i.d.
- Parenteral: 25 to 50 mg (1-2 mL) IM if symptoms persist after oral therapy.
- IV infusion: 25 to 50 mg (1-2 mL) in 500 to 1000 mL of saline if symptoms persist after IM therapy 2, 3.
From the Research
Treatment Options for Intractable Hiccups
- Various pharmacologic treatments have been proposed for intractable and persistent hiccups, including chlorpromazine, amitriptyline, baclofen, gabapentin, haloperidol, metoclopramide, midazolam, nifedipine, nimodipine, orphenadrine, and valproic acid 4
- Baclofen, gabapentin, and metoclopramide were the only agents that were studied in a prospective manner, while only baclofen and metoclopramide were studied in randomized controlled trials 4
- Tetrabenazine has been reported to be successful in treating intractable hiccups in a patient who was intolerant or unresponsive to classic antipsychotic agents 5
- Vagus nerve stimulation (VNS) has been reported to be effective in treating intractable hiccups, with significant improvement in symptoms following VNS insertion 6
- Risperidone, a second-generation antipsychotic, has been reported to be effective in abolishing intractable hiccups, suggesting that the serotonergic system may be involved in the pathophysiology of some hiccup cases 7
Pharmacological Agents
- Baclofen and gabapentin may be considered as first-line therapy for persistent and intractable hiccups, with metoclopramide and chlorpromazine in reserve 8
- Baclofen and gabapentin are less likely than standard neuroleptic agents to cause side effects during long-term therapy 8
- The use of baclofen and metoclopramide is supported by small randomized, placebo-controlled trials 8
- Observational data suggest that gabapentin and chlorpromazine are also effective in treating intractable hiccups 8