What medications are used to treat hiccups in a patient?

Medications for Treating Hiccups

Chlorpromazine is the first-line pharmacological treatment for persistent and intractable hiccups, dosed at 25-50 mg orally three to four times daily, with the option to escalate to 25-50 mg intramuscularly if oral therapy fails after 2-3 days. 1, 2

First-Line Pharmacotherapy

Chlorpromazine remains the gold standard dopamine receptor antagonist that interrupts the hiccup reflex arc at the medullary level 1:

• Dosing: 25-50 mg orally three to four times daily for intractable hiccups 2
• Escalation: If oral therapy fails after 2-3 days, administer 25-50 mg intramuscularly 2
• Critical monitoring: Watch for hypotension, sedation, extrapyramidal symptoms, and QT interval prolongation 3, 1, 4
• Special populations: Use lower doses in elderly patients who are more susceptible to hypotension and neuromuscular reactions 2

Second-Line Alternatives

When chlorpromazine is contraindicated or ineffective, metoclopramide is the recommended second-line agent 3, 1:

• Dosing: 10-20 mg orally or IV every 4-6 hours 1, 4
• Dual benefit: Acts as both a prokinetic and dopamine antagonist, particularly useful when gastroparesis or gastric outlet obstruction contributes to hiccups 1
• Monitoring: Requires surveillance for dystonic reactions; have diphenhydramine 25-50 mg available for treatment 1, 4
• Evidence base: Supported by randomized controlled trial data 3

Haloperidol serves as an alternative dopamine antagonist 1, 4:

• Dosing: 0.5-2 mg orally or IV every 4-6 hours 1, 4
• Context: Frequently used in palliative care settings 1
• Risks: Carries potential for extrapyramidal symptoms and QTc prolongation 1

Third-Line and Adjunctive Options

Baclofen represents an effective GABA-B agonist alternative 4:

• Dosing: Start with 5-10 mg three times daily 4
• Mechanism: Works through a different pathway than dopamine antagonists 4

Gabapentin has demonstrated efficacy, particularly for drug-induced hiccups 5:

• Evidence: Successfully treated aripiprazole-induced hiccups by reducing nerve impulse transmission and modulating diaphragmatic activity 5
• Mechanism: Modulates the hiccup reflex arc through calcium channel effects 5

Benzodiazepines (lorazepam 0.5-2 mg every 4-6 hours) may be helpful when anxiety contributes to the condition 1, 4:

• Context: Particularly useful when psychological factors are present 4

Cause-Specific Pharmacotherapy

When gastroesophageal reflux disease (GERD) is the suspected etiology 3, 4:

• Initial therapy: High-dose proton pump inhibitor (PPI) with concurrent antireflux diet and lifestyle modifications 3
• Response time: Variable from 2 weeks to several months 3
• Escalation: Add prokinetic therapy (metoclopramide) if partial or no improvement occurs 3
• Alternative: H2 blockers may be beneficial as adjunctive therapy 4

Critical Safety Considerations

Avoid concurrent use of multiple dopamine antagonists (chlorpromazine, metoclopramide, haloperidol) to prevent excessive dopamine blockade 1:

• QTc monitoring: Essential with all antipsychotic agents, especially with concurrent QT-prolonging medications 1
• Extrapyramidal symptoms: Monitor closely and treat with benztropine or diphenhydramine if they occur 4
• Elderly patients: Consider olanzapine 5 mg as an alternative due to better tolerability 1

Dosing Strategy

Use scheduled around-the-clock dosing rather than PRN dosing for persistent hiccups to maintain therapeutic drug levels 4:

• Rationale: Prevents breakthrough symptoms and maintains consistent reflex arc suppression 4

Common Pitfalls to Avoid

• Not monitoring for sedation with chlorpromazine, especially in elderly patients 4
• Overlooking drug-induced hiccups that may require discontinuation of the offending agent rather than adding more medications 4
• Underestimating QT prolongation risk with antipsychotics, particularly when combining with other QT-prolonging drugs 4
• Using multiple dopamine antagonists simultaneously without recognizing additive toxicity 1
• Failing to assess for underlying treatable causes such as metabolic abnormalities, CNS lesions, or gastric distension before initiating pharmacotherapy 1

When Standard Therapy Fails

For truly refractory cases after exhausting standard pharmacological options 1:

• Last resort: Consider nebulized lidocaine, but assess aspiration risk first 1
• Diagnostic workup: Ensure thorough evaluation for underlying causes including pericardial effusion compressing the phrenic nerve, which may require imaging with chest X-ray and echocardiography 3