Treatment Approach for Hiccups in Hospitalized Patients
For hospitalized patients with hiccups, chlorpromazine is the first-line pharmacological treatment, with dosing of 25-50 mg orally three to four times daily or 25-50 mg intramuscularly for persistent cases. 1, 2
Initial Non-Pharmacological Interventions
- Physical maneuvers should be attempted first for brief hiccups, including breath holding, drinking water rapidly, or stimulating the uvula or pharynx 3
- These physical disruptions of diaphragmatic rhythm are simple to implement and often effective for self-limited hiccups 4
- For patients on mechanical ventilation, adjusting ventilator settings may help reduce hiccup frequency 5
Pharmacological Management Algorithm
First-Line Treatment:
- Chlorpromazine (FDA-approved for hiccups)
- Oral dosing: 25-50 mg three to four times daily 2
- For persistent cases unresponsive to oral therapy (lasting 2-3 days): 25-50 mg IM 1
- For intractable cases: IV infusion of 25-50 mg in 500-1000 mL saline (patient should be lying flat with close blood pressure monitoring) 1
- Caution: Monitor for hypotension, sedation, and QT prolongation 6
Alternative Medications (when chlorpromazine is contraindicated or ineffective):
- Metoclopramide: First choice for hiccups of peripheral origin (gastric distention, GERD) 7
- Baclofen: First choice for hiccups of central origin (neurological causes) 7
- Gabapentin: Effective alternative with favorable side effect profile in rehabilitation patients 8
- Other options: Haloperidol, amitriptyline, midazolam (particularly in terminal illness) 9, 7
Special Considerations for Hospitalized Patients
Post-Extubation Hiccups
- For post-extubation stridor with hiccups, use nebulized epinephrine (1 mg) 5
- Consider high-flow oxygen therapy via nasal cannula after extubation, particularly for patients at risk of respiratory complications 5
- For patients with low cuff leak volume before extubation, consider prophylactic corticosteroids (prednisolone 1 mg/kg/day) at least 6 hours before extubation 5
Monitoring and Precautions
- When administering chlorpromazine IM, inject slowly into the upper outer quadrant of buttock 1
- Keep patient lying down for at least 30 minutes after injection to prevent hypotension 1
- For IV administration (severe cases only), dilute to at least 1 mg/mL and administer at a rate of 1 mg per minute 1
- Avoid subcutaneous injection 1
Treatment Based on Duration and Severity
- Brief hiccups (<48 hours): Non-pharmacological measures are usually sufficient 3
- Persistent hiccups (>48 hours): Begin pharmacological therapy with chlorpromazine 1, 2
- Intractable hiccups (>2 months): Consider consultation for interventional procedures such as nerve blocks if pharmacotherapy fails 7
Diagnostic Considerations
- For hiccups persisting beyond 48 hours, evaluate for underlying causes including thoracic pathology, central nervous system disorders, or medication side effects 6, 3
- Consider diagnostic workup including chest imaging for persistent cases 6
Common Pitfalls to Avoid
- Failing to identify and treat the underlying cause of hiccups 3
- Overlooking drug-induced hiccups (steroids, anesthetics, chemotherapy) 3
- Using sedative medications that may compromise respiratory function in already vulnerable patients 5
- Delaying treatment of persistent hiccups, which can interfere with nutrition, sleep, and overall recovery 8