What medications are used to treat hiccups?

Medications for Hiccups

For intractable hiccups, chlorpromazine 25-50 mg orally three to four times daily remains the only FDA-approved medication, though baclofen (5-10 mg three times daily) and metoclopramide (10-20 mg every 4-6 hours) are effective alternatives with potentially better tolerability profiles. 1, 2

First-Line Pharmacologic Options

Chlorpromazine (FDA-Approved)

• Chlorpromazine is the only FDA-approved medication specifically indicated for intractable hiccups, with dosing of 25-50 mg orally three to four times daily 1
• If symptoms persist for 2-3 days on oral therapy, parenteral administration may be indicated 1
• Major limitation: significant risk of sedation (especially in elderly), hypotension, and extrapyramidal symptoms 2, 3
• Monitor closely for QT prolongation, particularly problematic in patients with cardiac comorbidities 2
• Despite FDA approval, chlorpromazine often does not provide favorable results in rehabilitation settings and may not be the best first choice 4

Baclofen (Preferred Alternative)

• Start with 5-10 mg orally three times daily, which can be titrated upward as needed 2
• Baclofen is one of only two medications studied in randomized controlled trials for hiccups 3
• Generally better tolerated than chlorpromazine with fewer extrapyramidal effects 2
• Watch for sedation and hypotension, particularly at higher doses (up to 50 mg/day) 5

Metoclopramide

• Dose: 10-20 mg orally or intravenously every 4-6 hours 2
• Also studied in randomized controlled trials, demonstrating efficacy 3
• Prokinetic properties may be particularly useful when gastroesophageal reflux contributes to hiccups 6, 7
• Caution: Can cause extrapyramidal symptoms; avoid in patients with liver disease 8

Second-Line Options

Haloperidol

• Low doses of 0.5-2 mg daily provide antiemetic and anti-hiccup properties 2, 8
• Useful alternative antipsychotic when chlorpromazine is not tolerated 2
• May cause dyskinesia and somnolence at doses up to 6 mg/day 5

Gabapentin

• Studied prospectively with evidence of efficacy 3
• Dosing up to 1800 mg/day has been used successfully 4, 5
• Particularly effective in rehabilitation patients where chlorpromazine failed 4
• Main adverse effect is somnolence 5

Benzodiazepines (Lorazepam)

• Dose: 0.5-2 mg every 4-6 hours, especially when anxiety contributes to hiccups 2
• Can be administered orally, intravenously, or sublingually 9
• Useful adjunct to other antiemetic regimens 9, 8

Treatment Algorithm

Step 1: Initial Assessment

• Identify underlying cause (gastroesophageal reflux, central nervous system lesions, metabolic disturbances, drug-induced) 7
• Consider patient-specific factors: age, liver function, cardiac status, concurrent medications 8

Step 2: First-Line Pharmacotherapy

• For most patients: Start baclofen 5-10 mg three times daily OR metoclopramide 10-20 mg every 4-6 hours 2, 3
• For patients requiring rapid control: Chlorpromazine 25-50 mg three to four times daily, but monitor closely for adverse effects 1
• Avoid metoclopramide in liver disease; use haloperidol 0.5-2 mg or ondansetron instead 8

Step 3: If First-Line Fails After 48-72 Hours

• Add or switch to gabapentin, starting at lower doses and titrating to 1800 mg/day 3, 4
• Consider haloperidol 0.5-2 mg if antipsychotic properties needed 2
• Add lorazepam 0.5-2 mg every 4-6 hours if anxiety component present 2

Step 4: Refractory Cases

• Consider combination therapy with agents from different classes 7, 3
• Evaluate for non-pharmacologic interventions (nerve blockade, phrenic nerve pacing) 7
• In stroke patients unresponsive to standard therapy, tetrabenazine may be considered 5

Critical Management Considerations

Managing Extrapyramidal Symptoms

• If extrapyramidal symptoms develop from chlorpromazine or metoclopramide, administer benztropine 10
• Lorazepam can also treat acute dystonic reactions through GABA-mediated mechanisms 10
• For patients with prior extrapyramidal symptoms, avoid phenothiazines and consider ondansetron 10

Special Populations

• Elderly patients: Use lower doses of all agents, particularly chlorpromazine; increased susceptibility to hypotension and neuromuscular reactions 1
• Liver disease: Avoid prochlorperazine due to increased extrapyramidal symptom risk; prefer ondansetron or haloperidol 8
• Debilitated/emaciated patients: Increase dosage more gradually 1

Common Pitfalls to Avoid

• Not recognizing drug-induced hiccups (chemotherapy agents, corticosteroids, anesthetics) that may require discontinuation of the offending agent 7
• Overlooking gastroesophageal reflux as a treatable cause; consider adding H2 blockers or proton pump inhibitors 9, 8
• Underestimating sedation risk with chlorpromazine in elderly patients 2, 1
• Failing to monitor for QT prolongation when using chlorpromazine or other antipsychotics 2
• Not adjusting doses in hepatic impairment, which alters drug metabolism 8
• Using fixed PRN dosing instead of around-the-clock scheduled dosing for persistent hiccups 9