What is the treatment for chronic hiccups?

Management of Chronic Hiccups

For chronic hiccups, a stepwise approach is recommended, starting with physical maneuvers, followed by chlorpromazine 25-50 mg three times daily as first-line pharmacological therapy, with baclofen as a second-line option if chlorpromazine is ineffective or contraindicated. 1

Classification of Hiccups

Hiccups are classified based on duration:

• Acute hiccups: less than 48 hours
• Persistent hiccups: more than 48 hours but less than 2 months
• Intractable hiccups: more than 2 months

Step 1: Physical Maneuvers

Try these simple techniques first to disrupt the hiccup reflex arc:

• Breath holding
• Drinking water rapidly
• Swallowing granulated sugar
• Pulling on the tongue
• Stimulating the uvula/pharynx
• Larson's maneuver (suprasternal pressure)

Step 2: Identify and Treat Underlying Causes

Common underlying causes that must be addressed:

• Gastroesophageal reflux disease (GERD) - most common cause 2
• Myocardial ischemia
• Central nervous system disorders
• Medication side effects (steroids, anti-Parkinson drugs, anesthetics)
• Renal failure

For GERD-related hiccups: Start with a proton pump inhibitor (PPI) as first-line therapy 2

Step 3: Pharmacological Management

First-Line Medication:

• Chlorpromazine: 25 mg three times daily initially
• If ineffective after 2-3 days, increase to 50 mg three times daily 1, 3
• FDA-approved specifically for intractable hiccups 3

Alternative Medications:

• Baclofen: For central causes of hiccups or if chlorpromazine is ineffective
• Gabapentin: For neuropathic-related hiccups
• Metoclopramide: For peripheral causes, especially GI-related hiccups

Special Considerations

Monitoring:

• Watch for QT prolongation with chlorpromazine, especially if combined with other QT-prolonging medications
• Monitor for side effects such as hypotension, sedation, and extrapyramidal symptoms
• Use lower doses in elderly, debilitated, or emaciated patients 1, 3

For Refractory Cases:

• Consider referral for nerve blockade (phrenic or vagal)
• Acupuncture
• Nerve stimulation techniques

Common Pitfalls to Avoid

• Failing to identify underlying causes: Always evaluate for conditions like GERD, myocardial ischemia, or CNS disorders
• Overlooking drug interactions: Particularly with QT-prolonging medications
• Using high doses in vulnerable populations: Elderly patients require lower doses due to increased risk of adverse effects

Treatment Algorithm by Hiccup Duration

1. Acute hiccups (<48 hours):

   • Physical maneuvers first
   • If bothersome and persistent, consider chlorpromazine

2. Persistent hiccups (>48 hours but <2 months):

   • Start chlorpromazine 25 mg three times daily
   • If ineffective after 2-3 days, increase to 50 mg three times daily

3. Intractable hiccups (>2 months):

   • Consider IV chlorpromazine under careful monitoring
   • If medication-resistant, consider nerve blockade or other interventional approaches

By following this stepwise approach and addressing underlying causes, most cases of chronic hiccups can be effectively managed with significant improvement in quality of life.