What is the treatment for corticosteroids-induced hiccups?

Treatment for Corticosteroid-Induced Hiccups

Chlorpromazine is the first-line treatment for corticosteroid-induced hiccups, with a recommended dose of 25-50 mg orally, intramuscularly, or intravenously for adults. 1, 2

Pathophysiology and Clinical Context

Corticosteroid-induced hiccups represent an uncommon but distressing side effect of steroid therapy. Hiccups (singultus) can occur with various steroid formulations including:

• Oral corticosteroids (prednisone, dexamethasone)
• Intravenous corticosteroids
• Intra-articular injections 3
• Anabolic steroids 4, 5

The mechanism appears to involve steroid effects on the brainstem hiccup reflex arc, with steroids lowering the threshold for synaptic transmission in the midbrain 4.

Treatment Algorithm

First-Line Therapy

• Chlorpromazine (Thorazine): FDA-approved specifically for hiccups 1, 2
  • Dosing options:
    • Oral: 25-50 mg three times daily
    • IM: 25-50 mg (1-2 mL), repeating in 1 hour if necessary
    • IV (for intractable cases): 25-50 mg diluted in 500-1000 mL saline as slow infusion

Alternative Pharmacologic Options (if chlorpromazine fails or is contraindicated)

Based on systematic review evidence 6:

1. Baclofen: 5-10 mg three times daily
2. Gabapentin: 300-900 mg daily in divided doses
3. Metoclopramide: 10 mg three times daily
4. Haloperidol: 1-4 mg daily in divided doses

Non-Pharmacologic Approaches

• Consider temporarily discontinuing the corticosteroid if clinically feasible
• If corticosteroids must be continued, consider dose reduction
• Switch to a different corticosteroid formulation

Special Considerations

Monitoring

• Monitor blood pressure closely when using chlorpromazine, particularly with IV administration
• Keep patient lying down for at least 30 minutes after parenteral chlorpromazine
• Watch for sedation and extrapyramidal side effects with antipsychotics

Prevention

• Avoid repeat administration of the same corticosteroid formulation in patients with previous episodes of steroid-induced hiccups 3
• Consider prophylactic chlorpromazine when administering high-dose steroids to patients with prior history of steroid-induced hiccups

Pitfalls to Avoid

• Don't overlook the possibility that hiccups may be caused by the underlying condition rather than the steroid treatment
• Avoid prolonged use of chlorpromazine due to risk of tardive dyskinesia
• Don't delay treatment of persistent hiccups as they can lead to significant distress, dehydration, weight loss, and exhaustion

Evidence Quality

The evidence for managing corticosteroid-induced hiccups specifically is limited, with most recommendations based on case reports and clinical experience. Chlorpromazine remains the only FDA-approved medication for hiccups 6, though several other agents have shown efficacy in small studies and case series.

Most cases of steroid-induced hiccups resolve within 1-3 days of appropriate treatment or discontinuation of the offending steroid 7, 5.