What medications are used to treat hiccups?

Medications for Hiccups

First-Line Treatment

Chlorpromazine is the only FDA-approved medication for hiccups and should be the initial pharmacologic choice, dosed at 25-50 mg orally three to four times daily, with escalation to intramuscular administration (25-50 mg) if oral therapy fails after 2-3 days. 1

• The FDA label specifies that for intractable hiccups, if symptoms persist for 2-3 days on oral therapy, parenteral administration is indicated 1
• The American Academy of Pediatrics recognizes chlorpromazine as a dopamine receptor antagonist that interrupts the hiccup reflex arc at the medullary level 2
• Critical monitoring requirement: QTc prolongation, orthostatic hypotension, and dystonic reactions must be monitored, particularly in elderly patients 2
• Have diphenhydramine 25-50 mg available to treat extrapyramidal symptoms if they occur 2

Second-Line Alternatives When Chlorpromazine Fails or Is Contraindicated

Metoclopramide

• Metoclopramide 10-20 mg orally or IV every 4-6 hours is the preferred second-line agent, supported by randomized controlled trial evidence 3, 2
• Particularly useful when gastroparesis or gastric outlet obstruction contributes to hiccups due to its dual prokinetic and dopamine antagonist properties 2
• Monitor for dystonic reactions and have diphenhydramine available 2

Baclofen

• Baclofen 5-10 mg three times daily is an effective alternative with a favorable safety profile 3
• Emerged as a safe and often effective treatment in chronic hiccup management 4
• Baclofen and metoclopramide are the only agents studied in randomized controlled trials 5

Haloperidol

• Haloperidol 0.5-2 mg orally or IV every 4-6 hours can be used as an alternative dopamine antagonist 3, 2
• Commonly used in palliative care settings 2
• Carries risk of extrapyramidal symptoms and QTc prolongation 2

Third-Line Options

Benzodiazepines

• Lorazepam 0.5-2 mg every 4-6 hours is particularly helpful when anxiety contributes to hiccups 3, 2
• The American College of Physicians recommends benzodiazepines for hiccup treatment, especially with anxiety as a contributing factor 3
• Monitor for CNS depression, respiratory depression, and excessive sedation 6

Gabapentin

• Gabapentin has been studied prospectively and shown success in treating hiccups 5
• Consider when other agents fail or are contraindicated 5

Adjunctive Therapy for Underlying Causes

• Add H2 blockers or proton pump inhibitors when gastroesophageal reflux is suspected as the underlying cause 3
• The American Thoracic Society recommends considering GERD as a treatable cause of hiccups 3

Dosing Strategy

• Use around-the-clock scheduled dosing rather than PRN dosing for persistent hiccups 3
• The National Comprehensive Cancer Network recommends this approach for better symptom control 3

Critical Pitfalls to Avoid

• Do not overlook drug-induced hiccups—discontinue the offending agent if identified 3
• Avoid prochlorperazine in patients with liver disease due to increased risk of extrapyramidal symptoms 3
• Do not use multiple dopamine antagonists concurrently (chlorpromazine, metoclopramide, haloperidol) to avoid excessive dopamine blockade 7
• Screen for underlying metabolic abnormalities, CNS lesions, and gastric distension before initiating treatment 2
• Monitor QTc interval with all antipsychotic agents, especially with concurrent QT-prolonging medications 2

Management of Extrapyramidal Side Effects

• Treat dystonic reactions immediately with diphenhydramine 25-50 mg 2
• Benztropine is the alternative agent of choice in patients allergic to diphenhydramine 6
• Lorazepam 0.5-2 mg every 4-6 hours can also treat extrapyramidal symptoms 6

Special Population Considerations

Elderly Patients

• Start with lower doses in the lower range as elderly patients are more susceptible to hypotension and neuromuscular reactions 1
• Increase dosage more gradually and monitor closely 1
• Consider 5 mg olanzapine in oversedated elderly patients 7

Pediatric Patients (6 months to 12 years)

• Oral chlorpromazine: ¼ mg/lb body weight every 4-6 hours as needed 1
• Should generally not be used under 6 months of age except where potentially lifesaving 1