Management of hiccups in adults

PPI: proton pump inhibitor; FISST: forced inspiratory suction and swallow tool; GERD: gastroesophageal reflux disease; IM: intramuscular.

* Causes of persistent hiccups include central nervous system disease, gastroesophageal disease (including reflux), post-operative phrenic nerve irritation, intrathoracic or neck mass, foreign body in the external ear canal, acute heart disease, intra-abdominal processes, emotional stress/excitement, metabolic derangements including kidney failure and electrolyte abnormalities, and medications (eg, dexamethasone, diazepam, midazolam, barbiturates, tramadol, alpha methyl dopa, and certain anticancer drugs such as levofolinate, fluorouracil, oxaliplatin, carboplatin, irinotecan).

¶ Selection of PPI is based on patient and clinician preference, and standard GERD dosing is used. Refer to UpToDate content on management of GERD in adults.

Δ Hypnotherapy and acupuncture may be used for treatment for persistent hiccups concurrent with pharmacotherapy, although evidence of efficacy is limited.

◊ Most pharmacotherapies are initiated for 5 to 10 days. If hiccups subside, treatment can usually be stopped the day after cessation of hiccups. If not, we continue treatment for up to 15 days. If an agent is effective but hiccups recur after discontinuing it, longer-term usage of the agent may be needed. In some patients receiving palliative care, an indefinite duration of pharmacotherapy may be warranted.

§ For medications with dose ranges, we start at the lower dose and increase as needed.

¥ Chlorpromazine dose can be increased to 50 mg orally 3 times daily, if needed. In older adults and in patients in whom adverse effects develop that may be dose related (eg, hypotension, drowsiness), we use 10 mg orally 3 times daily. For patients with refractory hiccups that continue despite 2 to 3 days of oral treatment, or in patients unable to tolerate oral medications, chlorpromazine may be administered via an IM route. If symptoms persist after one IM dose, chlorpromazine may be administered as a single IV dose with appropriate cautions to minimize hypotension (ie, adequate hydration, slow infusion, supine positioning).