What medications are used to treat hiccups?

Medications for Hiccups

Baclofen (5-10 mg three times daily) and metoclopramide (10-20 mg every 4-6 hours) are the preferred first-line pharmacologic agents for persistent or intractable hiccups, with baclofen particularly effective for central causes and metoclopramide for peripheral causes. 1, 2

First-Line Pharmacologic Options

Baclofen

• Start with 5-10 mg three times daily as an effective alternative with good safety profile 1, 2
• Particularly effective for centrally-mediated hiccups 2
• Has emerged as a safe and often effective treatment in clinical practice 3

Metoclopramide

• Dose: 10-20 mg orally or IV every 4-6 hours 1, 2
• More effective for peripherally-mediated hiccups 2
• Monitor closely for extrapyramidal symptoms, especially in elderly patients and those with liver disease 2
• Have benztropine available to treat extrapyramidal reactions if they occur 2

Chlorpromazine

• The only FDA-approved medication specifically for intractable hiccups 4, 5
• Dose: 25-50 mg three or four times daily orally 4
• If symptoms persist for 2-3 days, parenteral therapy is indicated 4
• Critical monitoring required: Watch for sedation (especially in elderly), extrapyramidal symptoms, hypotension, and QT prolongation 1, 4
• Despite FDA approval, side effect profile limits its use as first-line therapy 5

Second-Line Options

Haloperidol

• Use low doses: 0.5-2 mg 1, 2
• Alternative antipsychotic with antiemetic and anti-hiccup properties 1
• Monitor for extrapyramidal symptoms and QT prolongation 2

Benzodiazepines (Lorazepam)

• Dose: 0.5-2 mg every 4-6 hours 1
• Particularly helpful when anxiety is a contributing factor 1
• Important caveat: These are sedating agents and should not be considered when non-sedative options are needed 2
• Monitor for CNS depression, respiratory depression, and paradoxical aggression in older adults 6

Adjunctive Considerations

Gastroesophageal Reflux Treatment

• Add H2 blockers or proton pump inhibitors when GERD is a treatable underlying cause 1
• Upper gastrointestinal pathology (ulcers, gastritis, esophagitis) is commonly observed in chronic hiccup patients 3

Dosing Strategy

• Use around-the-clock scheduled dosing instead of PRN dosing for persistent hiccups 1
• This approach provides more consistent symptom control 1

Critical Pitfalls to Avoid

Drug Selection Errors

• Avoid prochlorperazine in patients with liver disease due to significantly increased risk of extrapyramidal symptoms 1, 2
• Do not overlook drug-induced hiccups, which may require discontinuation of the offending agent rather than adding another medication 1

Monitoring Failures

• Always monitor for extrapyramidal symptoms with chlorpromazine, metoclopramide, and other antipsychotics 1, 2
• Check for QT prolongation when using haloperidol or chlorpromazine 1, 2
• Increase dosage more gradually in debilitated, emaciated, or elderly patients 4

Management of Extrapyramidal Reactions

• Benztropine is the agent of choice for treating dystonic reactions from these medications 6, 2
• Lorazepam can serve as an alternative for managing extrapyramidal symptoms 6

Algorithmic Approach

1. Start with baclofen (5-10 mg TID) or metoclopramide (10-20 mg q4-6h) based on suspected etiology (central vs. peripheral) 1, 2
2. If GERD is suspected, add H2 blocker or PPI 1
3. If anxiety is a contributing factor, consider adding lorazepam (0.5-2 mg q4-6h) 1
4. For refractory cases, escalate to chlorpromazine (25-50 mg TID-QID) with close monitoring 4
5. Haloperidol (0.5-2 mg) serves as an alternative antipsychotic option 1, 2
6. Keep benztropine readily available for extrapyramidal reactions 6, 2