Gabapentin for intractable hiccup

An Unusual Cause of Intractable Hiccups

Hiccups are a minor nuisance for most people and usually resolve within minutes. However, for some, they can persist for years and result in severe symptoms and even death. This case report describes a patient found to have a mediastinal lipoma resulting in intractable hiccups. The discussion highlights the pathophysiology, etiologies, and treatments of hiccups.

Gabapentin controlled substance status

Gabapentin is approved to treat postherpetic neuralgia and epilepsy with partial-onset seizures. The large majority of gabapentin prescribing is off label. Gabapentin may be abused for euphoria, potentiating the high from opiates, reduction of alcohol cravings, a cocaine-like high, as well as sedation or sleep. Individuals at the highest risk for abusing gabapentin include those with opioid abuse, mental illness, or previous history of prescription drug abuse. States are now taking action to track gabapentin use through prescription monitoring programs, and some states have reclassified it as a Schedule V controlled substance. This commentary summarizes gabapentin's abuse potential, identifies state-level actions regarding gabapentin monitoring, and discusses possible clinical implications and ways to enhance patient safety when prescribing gabapentin.

Steroid-Induced Hiccups in a Patient Managed for Pseudo Foster-Kennedy Syndrome: A Case Report of Good Outcome With the use of Gabapentin

The use of IV methylprednisolone has been shown to be associated with some adverse effects. The most feared side effect is acute gastrointestinal perforation and accelerated hypertension particularly during pulse therapy. Hiccups occur less frequently but can cause high levels of discomfort to the patient. In intractable cases, respiratory arrest and death can occur. This article reports the occurrence of hiccups in a patient managed for pseudo Foster-Kennedy syndrome. The hiccups were observed shortly after IV methylprednisolone was administered to the patient and abetted over a period of one week after it was discontinued. Hiccups occur through the neuronal pathway of the hiccup reflex arc, comprising the vagus nerve, phrenic nerve, parts of the sympathetic nervous system (T6-T12), and efferent fibers from the phrenic nerve that supply the glottis and the accessory muscles of respiration. The hiccups resolved with the use of gabapentin. This case report aims to add to the existing body of knowledge of the efficacy of gabapentin in the management of hiccups.

Persistent Postoperative Hiccups

Hiccups are a common and poorly understood pathologic phenomenon. While hiccups often occur suddenly and episodically, they may persist for weeks and sometimes months. There is a paucity of data regarding the precise etiology and optimal treatment for persistent hiccups. Frequently considered a benign and frustrating condition, hiccups are sometimes a presenting symptom for pulmonary embolism and cardiac disease. We present a patient with gastroesophageal reflux disease who developed 11 days of recurrent hiccups following an orthopedic procedure.

Management of hiccups in palliative care patients

Persistent hiccups are a frustrating experience for palliative care patients, and can have a profound impact on their quality of life. This article provides an evidence-based approach overview of the causes and treatment of this not infrequently debilitating condition for such patients, with a management algorithm. In situations where no readily reversible cause is identified, or where simple physical manoeuvres, such as breath holding have failed, a systematic approach is required. Hiccups can be broadly divided into central and peripheral types. These respond differently to pharmacological intervention. The drug of choice for central causes of persistent hiccups is baclofen, with metoclopramide recommended as the first choice for peripheral causes. Midazolam may be useful in cases of terminal illness. Interventional procedures such as vagal or phrenic nerve block or stimulation should be considered in patients who are refractory to medications. The management of persistent hiccups still presents an ongoing clinical challenge however, requiring further research on pathophysiology and treatment strategies. Multinational randomised controlled trials to evaluate and compare both current and new medications or procedures to better manage this difficult condition are suggested as a means of reaching this goal.

Development of Hiccup in Male Patients Hospitalized in a Psychiatric Ward: Is it Specifically Related to the Aripiprazole-Benzodiazepine Combination?

OBJECTIVES

The aim of this study was to identify hiccup cases among patients hospitalized in a psychiatric ward and focus on their treatment, so to establish intervention risk.

METHODS

We reviewed records of 354 consecutively admitted patients during the year 2013 to identify hiccup cases.

RESULTS

Hiccup occurred in 7 patients on both aripiprazole and benzodiazepines and in one on delorazepam. No patient on aripiprazole alone developed hiccup. No patient on drugs other than aripiprazole or benzodiazepines developed hiccup. The symptom subsided in 3 cases upon discontinuing aripiprazole and in 5 cases after discontinuing the benzodiazepine (including the case on delorazepam alone); in 2 cases of persistent hiccup, the symptom resolved after adding the calcium channel blocker, pregabalin. All patients developing hiccup were male. There was a 70-fold increase in the risk for developing hiccup in the aripiprazole/benzodiazepine intake condition versus all other conditions, and it further increased if limiting to the male sex.

LIMITATIONS

The retrospective nature of the study was its limitation.

CONCLUSIONS

Hospitalized psychiatric patients on both aripiprazole and benzodiazepines may be at significant risk of hiccup. This clinical awareness could lead to antipsychotic and/or benzodiazepine discontinuation or switch or to the addition of calcium channel blocker inhibitors.

Baclofen for stroke patients with persistent hiccups: a randomized, double-blind, placebo-controlled trial

Background

The results of preclinical studies suggest that baclofen may be useful in the treatment of stroke patients with persistent hiccups. This study was aimed to assess the possible efficacy of baclofen for the treatment of persistent hiccups after stroke.

Methods

In total, 30 stroke patients with persistent hiccups were randomly assigned to receive baclofen (n = 15) or a placebo (n = 15) in a double-blind, parallel-group trial. Participants in the baclofen group received 10 mg baclofen 3 times daily for 5 days. Participants assigned to the placebo group received 10 mg placebo 3 times daily for 5 days. The primary outcome measure was cessation of hiccups. Secondary outcome measures included efficacy in the two groups and adverse events.

Results

All 30 patients completed the study. The number of patients in whom the hiccups completely stopped was higher in the baclofen group than in the placebo group (relative risk, 7.00; 95% confidence interval, 1.91–25.62; P = 0.003). Furthermore, efficacy was higher in the baclofen group than in the placebo group (P < 0.01). No serious adverse events were documented in either group. One case each of mild transient drowsiness and dizziness was present in the baclofen group.

Conclusions

Baclofen was more effective than a placebo for the treatment of persistent hiccups in stroke patients.

Trial registration

Chinese Clinical Trials Register: ChiCTR-TRC-13004554

Gabapentin Therapy of Hiccups

OBJECTIVE:

To determine whether gabapentin is effective in the treatment of persistent or intractable hiccups.

DATA SOURCES:

A search of MEDLINE (1966-March 2013) using the MeSH search terms gabapentin, hiccups, and hiccups/drug therapy was performed. Additional databases searched included Web of Science (1945-March 2013) and International Pharmaceutical Abstracts (1970-March 2013) using the text words gabapentin and hiccups. Bibliographies of relevant articles were reviewed for additional citations.

STUDY SELECTION AND DATA EXTRACTION:

All data sources were considered for inclusion. Preference was given for articles written in English, although one abstract in German was used.

DATA SYNTHESIS:

Because of the low incidence of persistent or intractable hiccups, few if any controlled clinical trials are conducted on the efficacy of drug treatment. Therefore, most of the data involve case reports or case series. We evaluated 17 case reports and 2 case series involving gabapentin therapy for persistent or intractable hiccups. Therapeutic outcomes with gabapentin were positive in all cases, with temporal evidence suggesting an effect, but outcomes often were obscured by combination therapy and comorbidities in some cases. Case reports suggest that gabapentin might be useful as a second-line agent in patients undergoing stroke rehabilitation or in the palliative care setting where chlorpromazine adverse effects are undesirable. Gabapentin was very well tolerated, with only a few minor adverse effects.

CONCLUSIONS:

Gabapentin has a similar body of evidence as other pharmacotherapeutic agents used to treat hiccups. Gabapentin is well tolerated and should be considered as a second-line agent in selected patients.

Management of belching, hiccups, and aerophagia

Although belching and hiccups are regarded as normal behaviors, they can occur at high frequency or become persistent, becoming bothersome and requiring medical care. Patients with excessive belching frequently have supragastric belches. Excessive belching should be treated as a behavioral disorder. Persistent hiccups, however, can be the first presentation of a serious disorder that requires extensive diagnostic testing. When no cause is found, only the symptoms can be treated. Aerophagia is an episodic or chronic disorder in which patients (children and adults) swallow large quantities of air, which accumulate in the gastrointestinal tract to cause abdominal distention and bloating. These patients should not undergo explorative laparotomy because they do not have ileus. New treatment approaches are needed for patients with aerophagia.

Hiccup: mystery, nature and treatment

Hiccup is the sudden onset of erratic diaphragmatic and intercostal muscle contraction and immediately followed by laryngeal closure. The abrupt air rush into lungs elicits a "hic" sound. Hiccup is usually a self-limited disorder; however, when it is prolonged beyond 48 hours, it is considered persistent whereas episodes longer than 2 months are called intractable. A reflex arc involving peripheral phrenic, vagal and sympathetic pathways and central midbrain modulation is likely responsible for hiccup. Accordingly, any irritant in terms of physical/chemical factors, inflammation, neoplasia invading the arc leads to hiccups. The central causes of hiccup include stroke, space occupying lesions and injury etc, whereas peripheral causes include lesions along the arc such as tumors, myocardial ischemia, herpes infection, gastroesophageal reflux disease and applied instrumentations on human body etc. Besides, various drugs (eg, anti-parkinsonism drugs, anesthetic agents, steroids and chemotherapies etc) are the possible etiology. An effective treatment of persistent hiccup may be established upon the correct diagnosis of lesion responsible for the serious event. The pharmacotherapy of hiccup includes chlorpromazine, gabapentin, baclofen, serotonergic agonists, prokinetics and lidocaine. Non-pharmacological approaches such as nerve blockade, pacing, acupuncture and measures to hold breathing are also successful. Finally, alternative medicines and remedies are convenient to treat hiccups with uncertain effect. In conclusions, hiccup is likely to result from lesions involving the hiccup reflex arc. The lesion may need to be localized correctly for ablative treatment in patients with intractable hiccup. Apart from lesion ablation, drugs acting on reflex arc may be effective, while some other conventional measures may also be tried.

Low-dose Gabapentin for Intractable Hiccups in a Heart Transplant Recipient

Intractable hiccups can be a serious complication in transplant recipients. Unfortunately, many of the pharmacotherapies used to stop hiccups are associated with severe side effects as well as drug-drug interactions with immunosuppressants. We report a case of a heart transplant recipient who had had intractable hiccups for 2 months, resulting in severe insomnia, diminished appetite, and weight loss. To treat the hiccups, treatment with oral baclofen (5–10 mg 3 times daily) was started. After 6 weeks of therapy, the baclofen was titrated down and discontinued because it had not stopped the hiccups and was causing severe central nervous system side effects. Gabapentin (100 mg twice daily) was then prescribed and within 24 hours of the start of that treatment, the hiccups had resolved completely. After 3 weeks of therapy, the patient had no side effects and the gabapentin was subsequently discontinued. One year after stopping the gabapentin, the patient remains free of hiccups. Gabapentin appears to be a promising medication for the treatment of intractable hiccups in thoracic transplant recipients because of its lack of serious side effects at low doses, rapid onset of action, and lack of drug-drug interactions with transplant medications.

Gabapentin for Intractable Hiccups in Palliative Care

Intractable hiccups are not common in the general population or in the palliative care population but can adversely impact quality of life and cause other complications such as weight loss and sleep disturbance. Many treatments have been proposed for intractable hiccups, but there is little consensus regarding treatment in the medical literature. This is partly because hiccups are relatively uncommon and many of the proposed treatments are unproven or have long-term side effects. Pharmacologic treatments rather than home remedies or surgical treatments are more appropriate for the palliative care patient. Gabapentin is a promising medication for the treatment of intractable hiccups for its safety, lack of serious side effects, and rapid onset of action. Further research is indicated to determine whether gabapentin is consistently effective.

Refractory Hiccup

OBJECTIVE

To report a patient with intractable hiccup which improved with gabapentin.

CASE REPORT

A 69-year-old woman diagnosed with refractory hiccup that started 50 years before improved dramatically after a trial of gabapentin for essential tremor. Gabapentin withdrawal led to reappearance of hiccup, which improved again after its reintroduction.

CONCLUSIONS

Gabapentin should be considered as a possible therapy for refractory hiccup.