Alpha-2-delta ligands for singultus (hiccup) treatment: three case reports

Psychogenic hiccups in an older adult: A case report and literature review

Hiccups are typically benign and self-limiting. However, persistent or intractable hiccups can be debilitating, and may indicate the presence of an underlying physiological or psychological disorder. A 63-year-old man presented to the behavioral medicine clinic at a tertiary care hospital in Muscat, Oman, with a 4-year history of intractable hiccups. After exclusion of all organic causes of intractable hiccups, a diagnosis of psychogenic hiccups was made. Psychogenic hiccups are very rare, and only seven case series and reports have been published to date, according to PubMed and Google Scholar. This report includes a comprehensive review of the literature on all reported cases of psychogenic hiccups published to date, according to these two databases, to thoroughly investigate the effectiveness of various therapies for this condition. Psychogenic hiccups are very rare, and diagnosis should be made after exclusion of organic causes. Management can be challenging because of the lack of evidence-based interventions.

Perspectives on the Medical, Quality of Life, and Economic Consequences of Hiccups

PURPOSE OF REVIEW

Singultus or hiccups (HU) is a common, usually temporary, event. Its potentially serious consequences are often overlooked. This review explores published evidence describing HU burden (clinical, economic, and quality of life [QoL] consequences) across patient populations.

RECENT FINDINGS

Literature review identified 81 articles (including 57 individual case reports). We extracted relevant information to better understand the burden of HU and to identify knowledge gaps for future study. HU are physiologic events that can complicate existing medical conditions and treatments regardless of duration. Relatively short episodes can have devastating consequences in patients who have pre-existing conditions. HU appear to impact physical and psychological health, diminish QoL, increase healthcare resource use, and increase costs. A better understanding of HU burden is needed.

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.

Aripiprazole induced hiccups

Hiccups are a product of involuntary, intermittent spasmodic contraction of the diaphragm and inspiratory intercostal muscles that results in sudden inspiration and abrupt closure of the glottis. The exact pathophysiology of hiccups remains unknown. However, certain neurotransmitters, medications, and other factors have been implicated.

We report a case of a 38 year old patient who developed hiccups three days after adding aripiprazole 5 mg once a day to his medication regimen. Medical and environmental causes were ruled out and aripiprazole was discontinued. One day later, the hiccups resolved.

Several case reports have described patients who developed hiccups when treated with aripiprazole and related this to changes in neurotransmitter concentrations. However, due to limited literature, it was difficult to determine rate of occurrence of this adverse event with aripiprazole.

A temporal but not a causal relationship was observed between initiating aripiprazole and development of hiccups in this patient. A causal relationship cannot be established since the patient was not re-challenged with aripiprazole. Nonetheless, clinicians should be cognizant that use of aripiprazole may be associated with hiccups.

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.

Continuous subcutaneous infusion of lidocaine for persistent hiccup in advanced cancer

Persistent hiccup can cause anorexia, weight loss, disabling sleep deprivation, anxiety, and depression. Therefore, relief of persistent hiccup is important for advanced cancer patients and their family. Most reports on this condition are case series reports advocating the use of baclofen, haloperidol, gabapentin, and midazolam. However, these medications are occasionally ineffective or accompanied by intolerable side effects. The sodium channel blocker lidocaine has been shown to be effective in treating a variety of disorders thought to involve neuropathic mechanisms. Intravenous administration of lidocaine is common but efficacy has also been reported for subcutaneous infusion. In advanced cancer patients, subcutaneous infusion is easy, advantageous, and accompanied by less discomfort. We report a case of severe and sustained hiccup caused by gastric cancer that was successfully treated with a continuous subcutaneous infusion of lidocaine (480 mg (24 ml)/day) without severe side effects.

Anti-epileptic drugs

Therapeutic Reviews aim to provide essential independent information for health professionals about drugs used in palliative and hospice care. Additional content is available on www.palliativedrugs.com. Country-specific books (Hospice and Palliative Care Formulary USA, and Palliative Care Formulary, British and Canadian editions) are also available and can be ordered from www.palliativedrugs.com. The series editors welcome feedback on the articles (hq@palliativedrugs.com).

Acupuncture treatment for persistent hiccups in patients with cancer

OBJECTIVE

The objective of this study was to investigate the effects of acupuncture treatment for persistent hiccups in cancer patients.

DESIGN

The study design was a retrospective case series.

SETTINGS/LOCATION

The study setting was the Clinical Research Center of the National Institutes of Health.

SUBJECTS

The subjects were 16 adult male patients ages 27-71 with cancer, with persistent hiccups.

INTERVENTIONS

There were one to three acupuncture sessions over a 1-7-day period.

OUTCOME MEASURES

Treatment efficacy was measured using a hiccup assessment instrument pre- and post-treatment. The effects of acupuncture on common symptoms reported by all patients were also evaluated.

RESULTS

Thirteen (13) patients experienced complete remission of persistent hiccups (p < 0.0001); 3 patients experienced decreased hiccups severity. Significant improvement was observed in discomfort (p < 0.0001), distress (p < 0.0001), and fatigue (p = 0.0078).

CONCLUSIONS

This case series demonstrates that acupuncture may be a clinically useful, safe, and low-cost therapy for persistent hiccups in patients with cancer.

Novel use of amantadine: to treat hiccups

Persistent hiccups may have a considerable impact on general health through disturbance of diet, sleep, and mood. They can cause exhaustion, malnutrition, dehydration, wound dehiscence, and even death in extreme cases. We report a complex clinical case of intractable hiccups in a patient with cancer of the pancreas and Parkinson's disease and some of the problems encountered when attempting symptom control. We also discuss a potential therapeutic response to a novel agent, amantadine, unlicensed in the treatment of hiccups.

Aripiprazole-induced hiccups: a case report

Hiccups can arise from idiopathic, psychogenic and organic causes. The use of therapeutic drugs forms one of the important causes of hiccups. Although the exact pathophysiological processes involved have not yet been established, the neurotransmitters dopamine, serotonin and gamma amino butyric aid (GABA) have been documented to play a significant role in the generation of hiccups. We report a patient of organic bipolar affective disorder who developed hiccups with the atypical antipsychotic aripiprazole. The possible underlying neurotransmitter mechanisms, predisposing factors and clinical implications of this rare adverse event are discussed.