What are the management options for hiccups and nausea after taking lorazepam (Ativan) 2mg?

Management of Hiccups and Nausea After Lorazepam

For hiccups and nausea following lorazepam administration, the most effective approach is to use chlorpromazine for hiccups and a 5-HT3 antagonist such as ondansetron for nausea, while discontinuing lorazepam if possible.

Understanding the Association

• Benzodiazepines, including lorazepam, have been documented to cause hiccups as a side effect, with case reports specifically linking lorazepam 2mg to hiccup episodes lasting 45 minutes 1
• Nausea is a recognized adverse effect of lorazepam, particularly when used at higher doses 2
• These symptoms may be part of the drug's effect on the central nervous system and may be dose-dependent 1

Management of Hiccups

First-line options:

• Chlorpromazine is the only FDA-approved medication for hiccups and should be considered first-line therapy 3
  • Typical dose: 25-50mg orally every 6 hours as needed 4
• Baclofen is supported by small randomized controlled trials for persistent hiccups 5
  • Starting dose: 5-10mg three times daily

Second-line options:

• Metoclopramide 10-20mg orally or IV every 4-6 hours has shown efficacy in randomized trials 4, 5
• Gabapentin has shown effectiveness in observational studies with fewer side effects than neuroleptic agents 5

Management of Nausea

First-line options:

• Ondansetron 8mg orally or 4mg IV is effective for medication-induced nausea 4
• Prochlorperazine 10mg orally every 6 hours as needed 6

Second-line options:

• Dexamethasone 4-8mg orally can augment antiemetic therapy 4
• Promethazine 25mg orally or rectally every 6 hours 4

Comprehensive Approach

1. Discontinue lorazepam if clinically appropriate, as this is the likely causative agent 1
2. Treat hiccups with chlorpromazine or baclofen 3, 5
3. Treat nausea with ondansetron or prochlorperazine 4, 6
4. Consider combination therapy for persistent symptoms:
   • For persistent hiccups: Add gabapentin to chlorpromazine 5
   • For persistent nausea: Add dexamethasone to ondansetron 4

Special Considerations

• Monitor for sedation when using chlorpromazine, especially if the patient has already received lorazepam 4
• Be aware of potential QT prolongation with both ondansetron and chlorpromazine, particularly in patients with cardiac risk factors 4
• Lorazepam itself can cause withdrawal phenomena including rebound anxiety and insomnia if stopped abruptly after regular use 2
• If symptoms persist beyond 48 hours, evaluate for underlying causes beyond medication effect 5

Prevention for Future Use

• Consider using lower doses of lorazepam (0.5-1mg instead of 2mg) if the medication must be continued 1
• Pre-medication with ondansetron before lorazepam administration may prevent nausea 4
• Divided doses of lorazepam may reduce the incidence of side effects 4

This approach prioritizes effective symptom management while addressing the likely causative agent, with treatment options supported by the highest quality available evidence.