From the Guidelines
For persistent hiccups after failure of domperidone (Motilium) and metoclopramide, consider trying a 5-Hydroxytryptamine3 (5-HT3) receptor antagonist such as ondansetron or granisetron as your next option. These agents have been shown to be effective in improving nausea and vomiting in patients with refractory gastroparesis symptoms 1. The recommended dose for ondansetron is not specified in the context of hiccups, but for granisetron, a transdermal patch of 3.1 mg/24 h has been reported to decrease symptom scores by 50% in patients with refractory gastroparesis symptoms 1.
Alternatively, other options such as neurokinin (NK-1) receptor antagonists (e.g., aprepitant) or phenothiazine antipsychotics (e.g., prochlorperazine) may be considered, although their efficacy and safety profiles may vary 1. It's essential to weigh the potential benefits and risks of each treatment option and consider the individual patient's needs and medical history.
Non-pharmacological approaches, such as breathing techniques (breath holding, breathing into a paper bag) and stimulation of the vagus nerve through techniques like drinking cold water or gargling, should also be tried concurrently to help manage symptoms. Monitoring for medication side effects, particularly those related to the chosen treatment option, is crucial to ensure the best possible outcome for the patient. Treatment duration will depend on the individual case, but it typically ranges from a few days to several weeks or even longer for persistent cases.
From the Research
Treatment Options for Persistent Hiccups
Given that the patient has failed motilium and metoclopramide, the following alternatives can be considered:
- Baclofen: Supported by small randomized, placebo-controlled trials 2, and found to be successful in treating hiccups 3.
- Gabapentin: Also supported by observational data 2, and found to be successful in treating hiccups 3.
- Chlorpromazine: The only drug approved by the US Food and Drug Administration for the treatment of hiccups, and found to be effective in observational data 2.
- Other options: Amitriptyline, haloperidol, midazolam, nifedipine, nimodipine, orphenadrine, and valproic acid have been found in the literature to be successful in treating hiccups 3.
Considerations for Therapy Selection
When selecting a therapy, it is essential to consider the individual patient's underlying comorbidities, etiology of hiccups, and the properties of the drugs 3, 2.
Efficacy and Safety of Metoclopramide
Although metoclopramide has been found to be effective in treating intractable hiccups 4, the patient has already failed this treatment. However, it is worth noting that metoclopramide was found to have mild adverse events, including fatigue, upset mood, and dizziness 4.