Prescribe medication for a 65-year-old man with persistent hiccups lasting more than 48 hours and no contraindications.

Prescription for Persistent Hiccups in a 65-Year-Old Man

For a 65-year-old man with persistent hiccups lasting more than 48 hours, I recommend prescribing chlorpromazine 25–50 mg orally three to four times daily as first-line therapy, with close monitoring for orthostatic hypotension and QTc prolongation. 1, 2

Prescription Details

Chlorpromazine 25 mg tablets

• Sig: Take one tablet by mouth three to four times daily as needed for hiccups
• Dispense: #30 tablets
• Refills: 0 (reassess after initial trial)

Starting dose rationale: Begin with 25 mg three to four times daily rather than the higher 50 mg dose, given this patient's age (65 years) and the need for gradual titration in older adults. 2

Critical Monitoring Requirements

• Orthostatic blood pressure checks before each dose for the first 48–72 hours, as elderly patients are more susceptible to hypotension with chlorpromazine. 1, 2

• Baseline ECG and repeat ECG after 2–3 days to monitor for QTc prolongation, which is a significant risk with all antipsychotic agents used for hiccups. 1

• Watch for dystonic reactions (muscle spasms, particularly of the neck and face) and have diphenhydramine 25–50 mg available for immediate treatment if extrapyramidal symptoms occur. 1

• Assess for sedation and anticholinergic effects (dry mouth, urinary retention, confusion), which are more pronounced in elderly patients. 1

Treatment Timeline and Escalation

• If symptoms persist after 2–3 days of oral therapy at 25 mg three to four times daily, increase to 50 mg three to four times daily. 1, 2

• If oral therapy fails after 2–3 days at maximum tolerated dose, consider switching to intramuscular chlorpromazine 25–50 mg, though this requires close monitoring for hypotension. 2

• Maximum daily dose: Do not exceed 200 mg total daily in this elderly patient, as higher doses provide little additional benefit and substantially increase adverse effects. 2

Second-Line Alternatives (If Chlorpromazine Fails or Is Contraindicated)

Metoclopramide

• Dosing: 10–20 mg orally or IV every 4–6 hours, particularly useful if gastroparesis or gastric reflux contributes to hiccups. 1, 3
• Advantage: Dual mechanism as both prokinetic and dopamine antagonist. 1
• Monitoring: Watch for dystonic reactions; have diphenhydramine available. 1

Gabapentin

• Dosing: Start 300 mg twice daily, may increase as tolerated. 4, 5
• Advantage: Better long-term safety profile than neuroleptics, with fewer extrapyramidal symptoms and less risk of QTc prolongation. 4
• Evidence: Small randomized controlled trial data support efficacy, and case reports demonstrate effectiveness when chlorpromazine fails. 4, 5, 6

Baclofen

• Dosing: Titrate gradually to effective dose (typically 5–10 mg three times daily). 4
• Advantage: Approximately 60% initial response rate in randomized controlled trial, with fewer adverse effects than neuroleptics during long-term use. 4

Common Pitfalls to Avoid

• Do not prescribe chlorpromazine without baseline ECG in a 65-year-old patient, as undetected QTc prolongation increases risk of sudden cardiac death. 1

• Do not continue chlorpromazine beyond 2–3 weeks without reassessing the underlying cause of hiccups, as persistent symptoms may indicate serious pathology (CNS lesions, metabolic abnormalities, gastric distension). 1

• Do not use multiple dopamine antagonists concurrently (e.g., chlorpromazine + metoclopramide + haloperidol), as this causes excessive dopamine blockade and markedly increases extrapyramidal symptom risk. 3

• Do not ignore potential underlying causes: Before attributing hiccups to idiopathic causes, rule out gastroesophageal reflux disease (most common), metabolic disturbances, CNS lesions, phrenic nerve irritation, and medication-induced hiccups. 1, 7

When to Consider Empiric GERD Therapy First

• If the patient has any reflux symptoms (heartburn, regurgitation, nocturnal cough), consider starting high-dose proton pump inhibitor therapy (e.g., omeprazole 40 mg twice daily) before or concurrent with chlorpromazine, as GERD is a common reversible cause. 3

• Response time for PPI therapy is variable (2 weeks to several months), so do not abandon this approach prematurely if hiccups are GERD-related. 3

Alternative Prescription for Patients Who Refuse Neuroleptics

Gabapentin 300 mg capsules

• Sig: Take one capsule by mouth twice daily for hiccups
• Dispense: #60 capsules
• Refills: 1

This option is supported by case series data showing complete resolution of persistent hiccups after 30 days of gabapentin therapy, with better tolerability than chlorpromazine in rehabilitation patients. 5, 6