What is the recommended dose of baclofen (GABA receptor agonist) for treating intractable hiccups?

Baclofen Dosing for Intractable Hiccups

The recommended dose of baclofen for treating intractable hiccups is 5-10 mg three times daily, with a typical effective total daily dose of 30-60 mg. 1

Dosing Regimen

• Initial dose: Start with 5-10 mg three times daily 1
• Titration: Can be increased weekly by 10 mg/day up to 30 mg/day if needed 2
• Effective dose range: Total daily dose typically ranges from 15-60 mg, with most patients responding in the 30-60 mg range 1
• For older adults: Consider starting at lower doses (5 mg twice daily) due to increased sensitivity to side effects 1

Mechanism of Action

• Baclofen is a GABA-B receptor agonist that works as a muscle relaxant 1
• It is thought to reduce hiccups by activating inhibitory neurotransmitters that block the hiccup stimulus 3
• The drug's effect on GABA receptors helps decrease the reflex severity of hiccups 4

Evidence for Efficacy

• A double-blind, randomized, controlled, cross-over study demonstrated statistically significant improvement in hiccup severity with baclofen (p = 0.03) 4
• In a larger series of 37 patients with chronic hiccups (average duration 4.6 years), baclofen produced complete resolution in 18 cases and considerable decrease in 10 cases 5
• Systematic reviews support baclofen as a first-line therapy for persistent and intractable hiccups based on available efficacy and safety data 6

Clinical Considerations and Monitoring

• Monitor for common side effects, particularly in older adults:
  • Sedation and drowsiness 1
  • Cognitive impairment 1
  • Muscle weakness 1
  • Urinary dysfunction 1
• Use with caution in patients with:
  • Renal impairment (may require dose adjustment) 1
  • Hepatic encephalopathy (may worsen mental status) 1
• Avoid abrupt discontinuation as it may cause central nervous system irritability 1

Treatment Algorithm

1. Confirm diagnosis of intractable hiccups (lasting >48 hours)
2. Investigate and treat any underlying causes (especially gastroesophageal disorders) 5
3. Initiate baclofen at 5-10 mg three times daily 1
4. If inadequate response after 3-5 days, increase dose by 5-10 mg/day weekly up to 30 mg/day 2, 1
5. If still inadequate response at maximum dose (60 mg/day), consider:
   • Adding a second agent such as gabapentin 6
   • Or switching to alternative agents like metoclopramide or chlorpromazine 6

Special Populations

• In patients with liver disease: Baclofen has been specifically studied and shown to be safe in patients with alcoholic liver disease 1
• In elderly patients: Start at lower doses (5 mg twice daily) and titrate more slowly 1

Baclofen has demonstrated consistent efficacy in treating intractable hiccups across multiple studies and should be considered as first-line pharmacological therapy for this condition when non-pharmacological measures fail.