What is the treatment for unremitting hiccups?

Treatment for Unremitting Hiccups

Chlorpromazine is the first-line pharmacological treatment for unremitting hiccups, with a recommended dose of 25-50 mg three to four times daily orally, or 25-50 mg intramuscularly or intravenously for severe cases. 1, 2

First-Line Approach

Non-pharmacological Interventions

Try these simple measures first for acute hiccups:

• Stimulation of the pharynx (drinking cold water, gargling)
• Interrupting respiratory rhythm (breath holding, Valsalva maneuver)
• Carotid sinus massage
• Forced expiratory technique (huffing) 3

First-Line Pharmacological Treatment

If non-pharmacological measures fail and hiccups persist beyond 48 hours:

1. Chlorpromazine (Thorazine)
   • Oral: 25-50 mg three to four times daily 1
   • IM/IV: 25-50 mg, may repeat in 1 hour if needed 2
   • For IV administration: Dilute to 1 mg/mL and administer as slow infusion with patient lying flat 2

Second-Line Pharmacological Options

If chlorpromazine is ineffective or contraindicated, consider:

1. Baclofen

   • Has emerged as a safe and effective treatment 4
   • Start at low doses and titrate as needed

2. Gabapentin

   • Particularly effective for neurologically-mediated hiccups 5, 6

3. Metoclopramide

   • Especially useful when GI causes are suspected 7, 4

4. Other medications

   • Proton pump inhibitors (when GERD is the underlying cause) 8
   • Lidocaine (for refractory cases) 5

Addressing Underlying Causes

Persistent hiccups often indicate underlying pathology. Common causes include:

• Gastrointestinal disorders: GERD, gastritis, peptic ulcers (most common) 8, 4
• Central nervous system disorders: Stroke, tumors, trauma 5
• Thoracic disorders: Myocardial infarction, pneumonia 6
• Metabolic disorders: Uremia, electrolyte imbalances
• Medication-induced: Steroids, anesthetics, chemotherapy 5

Treatment Algorithm

1. Acute hiccups (<48 hours):

   • Try non-pharmacological measures
   • If persistent, consider chlorpromazine

2. Persistent hiccups (>48 hours to 2 months):

   • Start chlorpromazine 25-50 mg TID-QID
   • Investigate for underlying causes (especially GI disorders)
   • If GERD suspected, add PPI

3. Intractable hiccups (>2 months):

   • Continue pharmacotherapy with chlorpromazine or alternative agents
   • Consider combination therapy
   • For refractory cases, consider nerve blockade or stimulation 6

Special Considerations

• Elderly patients: Use lower doses of chlorpromazine (start with 10-25 mg) and monitor closely for hypotension 1, 2
• Hospitalized patients: IV administration may be necessary for severe cases
• Caution: Monitor for sedation, hypotension, and extrapyramidal side effects with chlorpromazine

Pitfalls to Avoid

• Failing to investigate underlying causes in persistent hiccups
• Overlooking GERD as a common trigger (should be ruled out in all cases)
• Using inadequate dosing of medications
• Delaying treatment, which can lead to complications like weight loss, exhaustion, and sleep deprivation 6

Remember that unremitting hiccups can significantly impact quality of life and may lead to serious complications including malnutrition, weight loss, exhaustion, and psychological distress if not properly treated.