What are the treatment options for intractable hiccups in an inpatient setting?

Management of Intractable Hiccups in the Inpatient Setting

Chlorpromazine 25-50 mg IV or IM three to four times daily is the first-line treatment for intractable hiccups in the inpatient setting, as it is the only FDA-approved medication for this condition. 1, 2

Pharmacological Treatment Algorithm

First-Line Treatment:

• Chlorpromazine
  • Dosing: 25-50 mg IV/IM three to four times daily 1, 2
  • If symptoms persist for 2-3 days, consider slow IV infusion with patient flat in bed: 25-50 mg in 500-1000 mL of saline 2
  • Monitor blood pressure closely during IV administration due to risk of hypotension
  • For elderly patients: Start with lower doses and titrate gradually 1

Second-Line Options:

• Metoclopramide

  • Dosing: 5-10 mg orally or IV four times daily, 30 minutes before meals and at bedtime 3
  • Mechanism: Dopamine antagonist with prokinetic properties
  • Supported by randomized controlled trials 4, 5

• Baclofen

  • Dosing: Start at 5-10 mg three times daily, increase as needed
  • Mechanism: GABA-B receptor agonist
  • Supported by small randomized, placebo-controlled trials 5

• Gabapentin

  • Dosing: Start at 300 mg daily, increase gradually to 900-1800 mg daily in divided doses
  • Mechanism: Calcium channel modulator
  • Lower risk of side effects during long-term therapy compared to neuroleptics 5

Non-Pharmacological Interventions

For cases refractory to pharmacological treatment:

1. Nerve Blockade

   • Phrenic nerve block under electromyography guidance 6
   • Consider for cases unresponsive to medication therapy

2. Vagus Nerve Stimulation

   • Emerging surgical option for intractable cases 7
   • Reserved for cases with significant morbidity where other treatments have failed

3. Treat Underlying Causes

   • Gastroesophageal reflux disease (GERD): Consider empiric trial of proton pump inhibitors 8, 9
   • For hiccups related to stroke or central nervous system disorders: Address primary condition

Special Considerations

• Elderly patients: Start with lower doses of all medications and titrate slowly due to increased risk of adverse effects 1, 2

• Monitor for adverse effects:

  • Chlorpromazine: Hypotension, sedation, extrapyramidal symptoms
  • Metoclopramide: Extrapyramidal symptoms, tardive dyskinesia with prolonged use
  • All neuroleptics: QT prolongation, especially with other QT-prolonging medications 3

• For patients with cancer or end-stage disease: Consider opioids if other treatments fail 3

Clinical Pitfalls to Avoid

• Avoid subcutaneous injection of chlorpromazine (use IM or IV routes only) 2
• When administering IV chlorpromazine, always dilute to at least 1 mg/mL and administer at a rate of 1 mg per minute 2
• Keep patients lying down for at least 30 minutes after parenteral administration of chlorpromazine to minimize hypotensive effects 2
• Don't overlook treating underlying causes, as management is most effective when directed at the primary condition 5
• Avoid long-term use of metoclopramide due to risk of tardive dyskinesia

Intractable hiccups can cause significant distress and morbidity for hospitalized patients. While chlorpromazine remains the only FDA-approved medication, a structured approach using alternative agents when needed can effectively manage this challenging condition.