From the Guidelines
For a 30-year-old male with intractable hiccups who hasn't responded to metoclopramide (Reglan), I recommend trying chlorpromazine 25-50 mg intramuscularly or intravenously as the next medication option, as it has been used to treat intractable hiccups and is mentioned in the provided evidence 1.
Alternative Options
- Baclofen 5-10 mg three times daily can be considered as an alternative option, although it is not mentioned in the provided evidence.
- Gabapentin starting at 300 mg three times daily, valproic acid 500 mg twice daily, or nifedipine 10 mg three times daily are other alternative medications that can be tried.
- Non-pharmacological interventions such as breathing into a paper bag, drinking cold water rapidly, gargling with ice water, or applying gentle pressure to the eyeballs can also be attempted.
- Physical maneuvers that stimulate the vagus nerve, like the Valsalva maneuver, can be helpful in stopping the hiccups.
Important Considerations
- Hiccups that persist beyond 48 hours warrant medical evaluation to identify potential underlying causes like gastroesophageal reflux disease, central nervous system disorders, metabolic abnormalities, or medication side effects.
- Chlorpromazine, being a phenothiazine, has anticholinergic properties and can cause QTc prolongation, which is a potential risk factor for dysrhythmias such as torsades de pointes, as mentioned in the provided evidence 1.
- Monitoring patients who receive chlorpromazine may include close clinical observation, cardiorespiratory monitoring, pulse oximetry, and/or an electrocardiogram, when and if the patient will tolerate them, as stated in the provided evidence 1.
From the FDA Drug Label
INTRACTABLE HICCUPS If symptoms persist for 2-3 days after trial with oral therapy, give 25 to 50 mg (1-2 mL) IM. Should symptoms persist, use slow IV infusion with patient flat in bed: 25 to 50 mg (1-2 mL) in 500 to 1000 mL of saline. Follow blood pressure closely.
For a 30-year-old male with intractable hiccups that did not respond to Reglan, Chlorpromazine (IM) can be considered. The recommended dose is 25 to 50 mg (1-2 mL) IM. If symptoms persist, a slow IV infusion can be used with the patient in a flat position, with a dose of 25 to 50 mg (1-2 mL) in 500 to 1000 mL of saline. It is essential to closely monitor blood pressure during administration 2.
From the Research
Intractable Hiccups in a 30-Year-Old Male
- The patient's condition of intractable hiccups that did not respond to Reglan (metoclopramide) is similar to a case reported in 3, where a 30-year-old male with intractable hiccups was found to have chronic pancreatitis with pseudocyst of the pancreas.
- The patient in 3 responded well to gabapentin, which may be considered as an alternative treatment option for the patient.
- Intractable hiccups can be a symptom of underlying medical conditions, and it is essential to investigate the cause of the hiccups, as highlighted in 3 and 4.
Possible Causes and Treatments
- Hiccups can result from various conditions, including metabolic abnormalities, central nervous system pathology, malignancy, medications, and disorders attributed to cardiac, pulmonary, and gastrointestinal etiologies, as reported in 4.
- Treatment options for intractable hiccups include dopamine-blocking medications, baclofen, gabapentin, and anticonvulsants, as mentioned in 5.
- Other therapies, such as physical disruption of the phrenic nerve, hypnosis, and acupuncture, have also been used in severe cases, as noted in 6.
Diagnostic Challenges
- Hiccups can be a diagnostic challenge, and an extensive evaluation may be necessary to determine the underlying cause, as seen in the case reported in 7, where a 75-year-old male with rebellious hiccup was diagnosed with a right ethmoid sinus tumor.
- The patient's symptoms and medical history should be thoroughly examined to identify potential underlying conditions that may be contributing to the intractable hiccups, as emphasized in 3 and 4.