Baclofen Dosing for Hiccups
For hiccups, baclofen should be initiated at 5 mg orally three times daily, with the option to increase to 10 mg three times daily if needed, based on the most consistent evidence from clinical practice. 1, 2
Initial Dosing Strategy
- Start with 5 mg orally three times daily as the initial dose, which has demonstrated efficacy in resolving persistent hiccups within 48 hours in documented cases 1
- Alternative starting dose of 10 mg three times daily (total 30 mg/day) is the most commonly prescribed regimen and represents standard practice, though it may carry higher risk of side effects 3, 2
- The lower starting dose (5 mg TID) is preferable to minimize common adverse effects including dizziness, somnolence, and gastrointestinal discomfort 4
Dose Titration and Duration
- Gradual dose escalation from 5 mg to 10 mg three times daily can be considered if hiccups persist after 48-72 hours on the lower dose 4, 1
- Treatment duration of 1 week is typically sufficient once hiccups resolve, after which baclofen can be discontinued 1
- In chronic cases (hiccups lasting >7 days), baclofen may need to be continued longer-term, with 28 of 37 patients (76%) achieving complete resolution or considerable decrease in one case series 2
Clinical Context and Efficacy Considerations
Baclofen appears more effective for chronic hiccups (>48 hours duration) compared to acute hiccups, with significantly better outcomes in this population (OR 0.51,95% CI: 0.29-0.91, p=0.02) 3. However, a large multisite study found that only 35% of patients overall achieved hiccup palliation with baclofen, falling short of the 75% threshold for robust efficacy 3.
- For acute hiccups (<48 hours): Consider observation or alternative treatments first, as baclofen showed limited benefit in this population 3
- For persistent/chronic hiccups (>48 hours): Baclofen is a reasonable first-line pharmacologic option, particularly when hiccups are idiopathic or related to gastroesophageal abnormalities 2
- Hiccups associated with lateral medullary syndrome or other neurologic causes may respond particularly well to baclofen due to its GABA-B receptor agonist mechanism 1, 5
Critical Safety Warnings
- Never abruptly discontinue baclofen, as withdrawal can cause life-threatening complications including hallucinations, delirium, rebound spasticity, rhabdomyolysis, multiorgan failure, and death 6
- Taper gradually when discontinuing, especially in patients on higher doses or prolonged therapy 4
- Monitor closely for CNS effects including drowsiness (most common adverse effect), dizziness, and altered mental status 4, 3
- Use caution in elderly patients and those with renal impairment, as baclofen is renally excreted and may accumulate 4
Mechanism and Alternative Considerations
Baclofen works as a GABA-B receptor agonist, likely interrupting the hiccup reflex arc by reducing dopamine release through GABA-B receptor stimulation 5. The American Gastroenterological Association recognizes baclofen as a treatment option for belching disorders and aerophagia, which may share pathophysiologic mechanisms with hiccups 4.
If baclofen fails or is contraindicated, investigate and treat underlying gastroesophageal abnormalities (fibroscopy, manometry, pH monitoring), as these are common contributors to chronic hiccups 2.