Is Thorazine (chlorpromazine) the best PRN (as needed) medication for hiccups?

From the Guidelines

Thorazine (chlorpromazine) is not the best PRN medication for hiccups due to its significant side effects and the availability of safer alternatives. While chlorpromazine can be effective for persistent hiccups, as noted in a study from 1, it carries significant side effects including sedation, hypotension, and extrapyramidal symptoms, making it generally reserved for severe, persistent cases that don't respond to first-line treatments. For most hiccup episodes, simpler interventions should be tried first, such as:

• Physical maneuvers (holding breath, breathing into a paper bag, drinking water from the opposite side of a glass)
• Over-the-counter medications like simethicone If medication is needed, other options are often preferred as first-line pharmacological treatments with better safety profiles, including:
• Baclofen (5-10mg three times daily)
• Gabapentin (300-900mg daily in divided doses)
• Metoclopramide (10mg) is another alternative with fewer side effects than chlorpromazine. Chlorpromazine should be considered only when other treatments fail, typically starting at 25-50mg orally or 25mg intramuscularly, and only under medical supervision due to its significant side effect profile, including the risk of QTc prolongation as discussed in 1.

From the FDA Drug Label

INTRACTABLE HICCUPS 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 answer to whether Thorazine (chlorpromazine) is the best PRN medication for hiccups cannot be directly determined from the provided information, as the label does not compare it to other medications for this purpose. However, it does provide dosage information for the treatment of intractable hiccups. Key points for the use of Thorazine in treating hiccups include:

• Dosage: 25 to 50 mg IM if symptoms persist after oral therapy
• Administration: Slow IV infusion may be used if symptoms persist, with the patient in a flat position Given the information provided in the drug label 2, Thorazine can be used for the treatment of intractable hiccups, but whether it is the "best" option cannot be concluded from the label alone.

From the Research

PRN Medication for Hiccups

• Thorazine (chlorpromazine) is the only drug approved by the US Food and Drug Administration for the treatment of hiccups 3.
• However, there is little evidence to support the use of one agent over another, and 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.
• Other pharmacologic treatments that have been proposed for intractable and persistent hiccups include baclofen, gabapentin, metoclopramide, and valproic acid 3, 4, 5.

Efficacy of Thorazine

• Observational data suggest that chlorpromazine is effective in treating hiccups, but there is no high-quality data to support its use as the best PRN medication 4.
• Baclofen and gabapentin may be considered as first-line therapy for persistent and intractable hiccups, with metoclopramide and chlorpromazine in reserve 4.
• A case report found that a combination of baclofen and olanzapine was effective in treating intractable hiccups in a patient who had failed other treatments 6.

Comparison with Other Medications

• Baclofen and gabapentin are less likely than standard neuroleptic agents, such as chlorpromazine, to cause side effects during long-term therapy 4.
• Metoclopramide has been studied in randomized controlled trials and has been found to be effective in treating hiccups 3, 4.
• The use of baclofen and metoclopramide is supported by small randomized, placebo-controlled trials, while observational data suggest that gabapentin and chlorpromazine are also effective 4.