Can propofol help with refractory hiccups?

Propofol for Refractory Hiccups

Propofol is not recommended for the treatment of refractory hiccups, as there is no evidence supporting its use for this indication, and it carries significant risks including respiratory depression, hypotension, and propofol infusion syndrome when used at high doses or for prolonged periods.

Evidence-Based Treatment Options for Refractory Hiccups

The literature on hiccup management does not include propofol as a therapeutic option. Instead, the following agents have evidence supporting their use:

First-Line Pharmacologic Agents

• Baclofen is the drug of choice for central causes of persistent hiccups, as it is a GABA analog that activates inhibitory neurotransmitters to block the hiccup stimulus 1, 2
• Metoclopramide is recommended as the first choice for peripheral causes of persistent hiccups 3, 2
• Metoclopramide and baclofen are the only agents studied in randomized controlled trials for hiccup management 3

Alternative Pharmacologic Options

• Chlorpromazine is the only FDA-approved drug specifically for hiccup treatment, though evidence is limited 3
• Gabapentin has been studied prospectively and shows efficacy in treating intractable hiccups 3
• Midazolam may be useful specifically in cases of terminal illness where hiccups are refractory to other treatments 2
• Other agents with case report evidence include: haloperidol, valproic acid, amitriptyline, nifedipine, nimodipine, and orphenadrine 3

Combination Therapy

• The combination of baclofen plus low-dose olanzapine has been reported to successfully control intractable hiccups when multiple single-agent regimens failed (including metoclopramide, desipramine, amantadine, cyclobenzaprine, phenytoin, and lorazepam) 1
• This represents the only published data on combination therapy for intractable hiccups 1

Why Propofol Is Not Appropriate

Lack of Evidence for Hiccup Treatment

• No published literature supports propofol use for hiccup management 3, 2
• Systematic reviews of pharmacologic interventions for intractable hiccups do not include propofol as a treatment option 3

Significant Safety Concerns

• Propofol infusion syndrome (PRIS) is a rare but potentially fatal complication characterized by acidosis, rhabdomyolysis, arrhythmias, myocardial failure, renal failure, and hepatomegaly 4
• In patients with refractory status epilepticus treated with propofol, 10% experienced sudden unexplained cardiorespiratory arrest (two fatal), and 35% had non-life-threatening features of PRIS 5
• PRIS risk increases with prolonged use (>48 hours) and high infusion rates (>70 μg/kg/min), though it can occur at lower doses 4

Cardiovascular and Respiratory Risks

• Propofol causes dose-dependent respiratory depression and hypotension due to systemic vasodilation 4, 6
• It decreases cardiac output, systemic vascular resistance, and arterial pressure 6
• Continuous monitoring of heart rate, blood pressure, and pulse oximetry is required, with readiness for mechanical ventilation 4, 6

Recommended Treatment Algorithm

For central causes (CNS pathology):

• Start with baclofen as first-line therapy 2

For peripheral causes (gastrointestinal, diaphragmatic irritation):

• Start with metoclopramide as first-line therapy 2

For refractory cases:

• Consider adding olanzapine to baclofen 1
• Trial gabapentin as an alternative 3
• In terminal illness, consider midazolam 2

For truly intractable cases:

• Interventional procedures such as vagal or phrenic nerve block or stimulation should be considered before resorting to agents with significant systemic risks 2