Hiccups Medication
- Author: Garry Wilkes, MBBS, FACEM; Chief Editor: Steven C Dronen, MD, FAAEM more...
Medication Summary
Various agents have been reported to cure hiccups. Chlorpromazine is the most studied and appears to be the drug of choice. Increments of 25-50 mg IV/IM are effective in 80% of cases. To avoid or minimize hypotension from the agent, preloading the patient with 500-1000 mL of IV fluid is advised.
Another major tranquilizer, haloperidol, is effective in doses of 2-5 mg. Metoclopramide has been used successfully in a dose of 10 mg every 8 hours.
Several anticonvulsant agents have been used to treat intractable hiccups. Phenytoin, valproic acid, and carbamazepine have been effective when used in typical anticonvulsant doses. Gabapentin has been shown to be effective where CNS lesions are present and in some other etiological groups.[17, 18, 19]
Of the anesthetic agents, ketamine has been the most successful at a dose of 0.4 mg/kg (one fifth of the usual anesthetic dose). Baclofen,[20] a centrally acting muscle relaxant, administered at 10 mg PO 4 times a day, particularly is useful in patients for whom other agents are contraindicated (eg, those with renal impairment). Intravenous lidocaine in a loading dose of 1 mg/kg, followed by an infusion of 2 mg/min, has cured patients after other agents were unsuccessful.
Other agents reported to be beneficial include muscle relaxants, sedatives, analgesics (eg, orphenadrine, amitriptyline, chloral hydrate, morphine), stimulants (eg, ephedrine, methylphenidate, amphetamine, nikethamide), and a miscellaneous group including edrophonium, dexamethasone, amantadine,[8] and nifedipine. Benzodiazepines have been shown to exacerbate or precipitate hiccups and should be avoided.[11]
Antiemetics
Class Summary
These agents are effective in treating hiccups.
Chlorpromazine (Thorazine)
DOC; antidopaminergic drug; blocks postsynaptic mesolimbic dopamine receptors; has anticholinergic effect; can depress the reticular activating system (possibly all are responsible for relieving nausea and vomiting); blocks alpha-adrenergic receptors; depresses release of hypophyseal and hypothalamic hormones.
Metoclopramide (Reglan)
Blocks dopamine receptors in the chemoreceptor trigger zone of CNS.
Anticonvulsants/antiarrhythmic
Class Summary
These agents are used for severe muscle spasms.
Phenytoin (Dilantin)
Inhibits spread of motor activity by acting in motor cortex.
Valproic acid (Depakote, Depakene)
Although mechanism of action is not established, activity may be related to increased brain levels of gamma-aminobutyric acid (GABA), or enhanced GABA action. Valproate may also potentiate postsynaptic GABA responses, affect potassium channel, or have a direct membrane-stabilizing effect.
Carbamazepine (Tegretol)
May block post-tetanic potentiation by reducing summation of temporal stimulation.
Anesthetics
Class Summary
Agents with effects in muscle contractions appear to be effective.
Ketamine (Ketalar)
Acts on the cortex and limbic system, decreasing muscle spasms.
Lidocaine (Dilocaine, Xylocaine, Anestacon)
Inhibits depolarization of type C sensory neurons by blocking sodium channels.
Muscle relaxants
Class Summary
These agents may reduce muscle contractions.
Orphenadrine (Norflex)
While exact mode of action not well understood, has shown clinical effectiveness in treating hiccups.
Baclofen (Lioresal)
May induce the hyperpolarization of afferent terminals and inhibit both monosynaptic and polysynaptic reflexes at the spinal level. Useful in patients for whom other agents are contraindicated (eg, those with renal impairment).
Sedatives
Class Summary
Agents with effects in spastic muscles have shown effectiveness.
Morphine (Duramorph, Astramorph)
DOC for analgesia due to reliable and predictable effects, safety profile, and ease of reversibility with naloxone.
Various IV doses are used; commonly titrated until desired effect obtained.
Haloperidol (Haldol)
Useful in treatment of irregular spasmodic movements of muscles.
Chloral hydrate (Aquachloral, Supprettes)
Has central nervous system depressant effects. Mechanism unknown.
Tricyclic antidepressants
Class Summary
A complex group of drugs that have central and peripheral anticholinergic effects as well as sedative effects. They block the active reuptake of norepinephrine and serotonin.
Amitriptyline (Elavil)
Inhibits reuptake of serotonin and/or norepinephrine at presynaptic neuronal membrane, which increases concentration in CNS. May also have analgesic effects.
Stimulants
Class Summary
Mechanisms of action in the treatment of hiccups are not well understood.
Ephedrine (Pretz-D)
Stimulates release of epinephrine stores, producing alpha-adrenergic and beta-adrenergic effects.
Methylphenidate (Ritalin)
Stimulates cerebral cortex and subcortical structures.
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