What is the treatment for persistent hiccups?

Management of Persistent Hiccups

Chlorpromazine is the first-line medication for persistent hiccups, with an initial dose of 25-50 mg three times daily, which can be increased if symptoms persist after 2-3 days. 1, 2

Classification of Hiccups

Hiccups are classified based on duration:

• Acute: Less than 48 hours
• Persistent: More than 48 hours but less than 2 months
• Intractable: More than 2 months 1

Treatment Algorithm

First-Line Approaches (Acute Hiccups)

1. Physical maneuvers (attempt these first):
   • Breath-holding
   • Rapid water drinking
   • Swallowing granulated sugar
   • Pulling on the tongue
   • Stimulating the uvula/pharynx
   • Larson maneuver (supraglottic lift)
   • HAPI technique (Hiccup relief using Active Prolonged Inspiration): Have patient inspire maximally, then continue attempting to inspire with an open glottis for 30 seconds, followed by slow expiration 3

Second-Line Approaches (Persistent Hiccups)

If physical maneuvers fail and hiccups persist beyond 48 hours:

1. Pharmacological treatment:

   • Chlorpromazine: 25-50 mg three times daily (first-line medication) 1, 2
   • Increase to 50 mg three times daily if ineffective after 2-3 days
   • FDA-approved specifically for intractable hiccups 2

2. Alternative medications (if chlorpromazine is contraindicated or ineffective):

   • Baclofen
   • Gabapentin
   • Metoclopramide 1, 4

Third-Line Approaches (Intractable Hiccups)

For hiccups persisting beyond 2 months:

1. IV chlorpromazine under careful monitoring 1

2. Advanced interventions:

   • Nerve blocks (phrenic nerve)
   • Nerve stimulation
   • Acupuncture 1, 4

Special Considerations

Dose Adjustments

• Elderly patients: Use lower doses due to increased susceptibility to hypotension and neuromuscular reactions 2
• Debilitated or emaciated patients: Increase dosage more gradually 2

Monitoring and Safety

• Monitor for hypotension, sedation, and extrapyramidal symptoms with chlorpromazine
• Consider QT prolongation risk, especially when combining with other QT-prolonging medications 1

Underlying Causes

Always investigate and treat potential underlying causes:

• Gastroesophageal reflux disease
• Myocardial ischemia
• Central nervous system disorders
• Medication side effects
• Metabolic disorders
• Abdominal pathology 4, 5

Pediatric Considerations

• Chlorpromazine dosing for children (6 months to 12 years): 0.25 mg/lb body weight every 4-6 hours as needed
• Should generally not be used in children under 6 months except in potentially life-saving situations 2

Failure to identify and treat underlying causes can lead to prolonged or intractable hiccups, significantly impacting quality of life through complications such as weight loss, sleep deprivation, and depression 5.