Each week we will aim to bring out a concise email that provides 4-5 key pieces of information addressing a specific issue in clinical therapeutics. This week:
A hiccup (also sometimes referred to as hiccough or singultus) is an involuntary, intermittent, spasmodic contraction of the diaphragm and intercostal muscles followed by laryngeal closure. Usually transient, hiccups can sometimes be persistent (> 48 hours or < 30 days) or intractable (> 30 days). Comorbidities such as vascular disease, CNS conditions, duodenal pathology and postoperative recovery have been associated with intractable hiccups. Intractable hiccups can cause malnutrition, weight loss, fatigue, dehydration, insomnia and mental stress.
- Medications known to be associated with persistent hiccups include dexamethasone, diazepam, opioids, dopamine agonists used in Parkinson’s disease and various antineoplastic agents.
- Comparative controlled studies of various treatment options do not appear to have been undertaken. Treatment should initially address potential underlying causes (e.g. acid suppression in gastro-oesophageal reflux disease). Physical manoeuvres are usually recommended initially. Approaches have included breath holding, breathing into a paper bag (elevation of PaCO2 may be inhibitory), Valsalva manoeuvre, sipping cold water, gargling, eyeball pressure, knees to chest and leaning forward.
- If physical measures fail it may be necessary to consider drug treatment. Successful treatments can usually be stopped the day hiccups cease, and medications are usually trialed for 7-10 days before seeking alternative treatment. In some cases, treatment may be required for several months. Assessment should include a review for adverse effects of medication, and should be used to guide dose and duration of pharmacotherapy.
- Medications that have been used with some success in the management of intractable hiccups include metoclopramide, chlorpromazine and baclofen. Case reports also describe the use of gabapentin, amitriptyline and carbamazepine. In the context of palliative care, haloperidol +/- clonazepam have also use used with success.
Please consider these issues when preparing or interpreting RMMR reports or education sessions. Contributions of content or suggested topics are welcome and should be sent directly to firstname.lastname@example.org