What is the best approach for managing persistent hiccups?

From the Guidelines

For managing persistent hiccups, titrating a dopamine receptor antagonist, such as prochlorperazine, haloperidol, metoclopramide, or olanzapine, to maximum benefit and tolerance is the best approach. This recommendation is based on the most recent and highest quality study available, which emphasizes the importance of dopamine receptor antagonists in the management of persistent hiccups 1.

When considering the management of persistent hiccups, it's essential to prioritize interventions that can provide the most significant benefit with the least amount of risk. The use of dopamine receptor antagonists is supported by guidelines that outline a stepwise approach to managing symptoms like nausea and vomiting, which can be associated with hiccups 1.

Some key points to consider in the management of persistent hiccups include:

• Starting with a dopamine receptor antagonist and adjusting the dose to achieve maximum benefit while minimizing side effects.
• If hiccups persist, considering the addition of other agents such as a 5-HT3 antagonist (e.g., ondansetron) or an anticholinergic agent (e.g., scopolamine) as part of a comprehensive management plan 1.
• The importance of addressing any underlying conditions that may be contributing to the hiccups, such as gastroesophageal reflux disease (GERD), and managing these conditions appropriately.
• Avoiding triggers that can exacerbate hiccups, such as carbonated beverages, alcohol, and spicy foods, as part of a holistic approach to management.

In clinical practice, the goal is to balance the effectiveness of the treatment with the potential for side effects and the quality of life of the patient. Therefore, the initial use of dopamine receptor antagonists, with adjustment and addition of other agents as needed, is a practical and evidence-based approach to managing persistent hiccups 1.

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. The best approach for managing persistent hiccups is to administer chlorpromazine (PO) at a dosage of 25 mg to 50 mg three to four times a day. If symptoms persist for 2 to 3 days, consider parenteral therapy 2.

From the Research

Persistent Hiccups Management

• The management of persistent hiccups can be challenging, and there is no single best approach for all patients 3, 4.
• Pharmacologic interventions, such as chlorpromazine, baclofen, gabapentin, and metoclopramide, have been proposed for the treatment of intractable and persistent hiccups 3, 4.
• Baclofen and gabapentin may be considered as first-line therapy for persistent and intractable hiccups, with metoclopramide and chlorpromazine in reserve 4.
• A systematic review of 15 published studies found that treatment of persistent or intractable hiccups was most effective when directed at the underlying condition, and an empirical trial of anti-reflux therapy may be appropriate 4.
• Baclofen has been shown to be effective in treating hiccups in some patients, particularly those with chronic hiccups (>48 hours duration) 5, 6.
• Combination therapy, such as baclofen and olanzapine, may also be effective in treating intractable hiccups, although strong evidence for a specific treatment regimen is lacking 7.

Treatment Options

• Chlorpromazine: approved by the US Food and Drug Administration for the treatment of hiccups, but its use is not supported by strong evidence 3.
• Baclofen: a GABA(B) receptor agonist that has been shown to be effective in treating hiccups, particularly in patients with chronic hiccups 5, 6.
• Gabapentin: an anticonvulsant medication that has been proposed as a treatment for hiccups, although its effectiveness is not well established 3, 4.
• Metoclopramide: a prokinetic agent that has been used to treat hiccups, although its effectiveness is not well established 3, 4.
• Olanzapine: an atypical antipsychotic medication that has been used in combination with baclofen to treat intractable hiccups, although its mechanism of action is not fully understood 7.

Considerations

• Therapy selection should be specific to individual patients, their underlying comorbidities, etiology of hiccups, and take into account the individual properties of the drugs 3.
• Adverse events, such as drowsiness, can occur with the use of pharmacologic agents, such as baclofen 5.
• Further study is needed to determine the effectiveness of pharmacologic agents, such as baclofen, in treating persistent and intractable hiccups 5.