Perphenazine-induced hiccups

Protracted Hiccups Induced by Aripiprazole and Regressed after Administration of Gabapentin

Hiccups are sudden, repeated, and involuntary contractions of the diaphragm muscle (myoclonic contraction). It involves a reflex arc that, once activated, causes a strong contraction of the diaphragm immediately followed by the closure of the glottis translating into the classic "hic" sound. Hiccups can be short, persistent, and intractable depending on the duration. The most disabling hiccups often represent the epiphenomenon of a medical condition such as gastrointestinal and cardiovascular disorders; central nervous system (CNS) abnormalities; ear, nose, and throat (ENT) conditions or pneumological problems; metabolic/endocrine disorders; infections; and psychogenic disorders. Some drugs, such as aripiprazole, a second-generation antipsychotic, can induce the onset of variable hiccups. We describe herein the cases of three hospitalized patients who developed insistent hiccups after taking aripiprazole and who positively responded to low doses of gabapentin. It is probable that aripiprazole, prescribed at a low dosage (<7.5 mg/day), would act as a dopamine agonist by stimulating D₂ and D₃ receptors at the "hiccup center" level-located in the brain stem-thus triggering the hiccup. On the other hand, gabapentin led to a complete regression of the hiccup probably by reducing the nerve impulse transmission and modulating the diaphragmatic activity. The present case series suggests the use of low doses of gabapentin as an effective treatment for aripiprazole-induced hiccups. However, our knowledge of the neurotransmitter functioning of the hiccup reflex arc is still limited, and further research is needed to characterize the neurotransmitters involved in hiccups for potential novel therapeutic targets.

Possible Sertraline-Induced Hiccups in a Boy With Obsessive-Compulsive Disorder and Attention-Deficit/Hyperactivity Disorder

Hiccup is a sudden-onset repeated involuntary and spasmodic contraction of the diaphragm and intercostal muscle accompanied by laryngeal closure, generating the characteristic inspiratory sound and discomfort. Various factors including drugs may trigger the hiccups. There are some reports regarding the possible links between psychotropic agents that can affect the dopaminergic system and the triggering of hiccup; however, to our knowledge, there are no data regarding sertraline-induced hiccup. We present the case of a boy with obsessive-compulsive disorder and attention-deficit/hyperactivity disorder who displayed hiccup after sertraline therapy.

Intractable hiccups (singultus) abolished by risperidone, but not by haloperidol

Hiccups or singulata are rhythmic involuntary movements of the diaphragm, caused by a variety of conditions that interfere with the functions of the nerve nuclei in the medulla and supra-spinal hiccup center. Although neurotransmitters and receptors involved in the pathophysiology of hiccups are not defined well, dopamine has been considered to play an important role. In some cases, chlorpromazine or other antipsychotics are used for the treatment of intractable hiccups but their efficacy is often limited. This report involves an 18-year-old patient who experienced two episodes of intractable hiccups triggered by stress, which lasted for weeks or even months. In both episodes, haloperidol was initially used, but there was no significant effect. In contrast, risperidone, the second-generation antipsychotic that possesses a dopamine-serotonin antagonist property, completely abolished the hiccups 6 hours after administration. This is one of few case reports in which two antipsychotics were challenged for a single patient with hiccups, and the effects of the drugs were obviously different. Our finding suggests that, in addition to dopaminergic system, the serotonergic systems may be involved in the pathophysiology of some hiccup cases and that the serotonin-acting antipsychotics such as risperidone should be considered as a choice in the drug treatment of intractable hiccups.

Aripiprazole-associated hiccups: a case and closer look at the association between hiccups and antipsychotics

Aripiprazole's pharmacologic properties (including dopamine 2 and 5-hydroxytryptamine 1A [5HT1A] receptor partial agonism and 5HT2A receptors antagonism) may be associated with the onset of hiccups.

CASE DESCRIPTION

A 21-year-old, antipsychotic-naive patient with bipolar I disorder and remote brain trauma developed persistent hiccups following aripiprazole titration. Despite trials of metoclopramide and chlorpromazine, hiccups continued. Remission of hiccups occurred with discontinuation of aripiprazole.

DISCUSSION

The exact etiology of hiccups is unknown but likely involves dopamine and/or γ-butyric acid. Highlighting the uncertainty related to drug-induced hiccups is the fact that multiple antipsychotics have been reported to not only induce hiccups but also to alleviate them. As the development of persistent hiccups may result in extensive medical workup, clinicians should be aware of drug-associated causes including aripiprazole.

Transient hiccups associated with oral dexamethasone

Hiccups, or singulata (hiccup is singultus), are commonly experienced by most people at one time or another and are usually brief and self-limiting. Although pharmacotherapeutic agents are not generally considered causal in the etiology of hiccups, many clinicians empirically associate episodic hiccups in their patients as being drug induced. The two classes of drugs most often cited as causing hiccups are corticosteroids and benzodiazepines. This report involved a patient who was given preoperative dexamethasone and developed hiccups before anesthesia and surgery commenced. He at no time was in distress, and the surgical procedure was completed without complication. By the second postsurgical day his hiccups were resolved completely. Although the association may be anecdotal, many clinicians consider hiccups a potential side effect of steroid therapy, especially high doses of steroids. Of interest in this case is the relatively low dose of corticosteroid used, albeit apparently linked to his hiccups. Practitioners should be aware of this potential condition.

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.

Hiccups in Parkinson's disease: an overlooked non-motor symptom?

INTRODUCTION

Although hiccups may be a non-motor symptom of Parkinson's disease (PD), they have attracted little research attention to date.

OBJECTIVE

To investigate the frequency of occurrence of hiccups in PD.

METHOD

The presence of hiccups was evaluated using face-to-face interviews in 90 PD patients and 100 age-matched controls.

RESULTS

Eighteen (20%) of the PD patients and three (3%) of the control subjects reported frequent hiccups. The reported occurrence of hiccups was significantly higher in PD patients than controls. Nine patients noted that hiccups had appeared in the past, particularly around the onset of PD. One patient was admitted to our hospital because of intractable hiccups before a diagnosis of PD was made. Another eight patients reported the emergence of hiccups following the administration of antiparkinsonian drugs.

CONCLUSION

Our results suggest that hiccups are more frequent in PD patients than healthy controls. Further studies are required to determine whether hiccups are associated with intrinsic pathology, to dopamine replacement therapy, or both.

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.

Hiccup and neurosurgeons: a report of 4 rare dorsal medullary compressive pathologies and review of the literature

OBJECTIVE

The aim of this study was to present 4 rare cases of medullary compressive lesions presenting with IH, to discuss the indications for neurosurgical decompression in such cases, and to review the possible etiologies of IH briefly.

METHODS

The reported cases include (1) a 19-year-old adolescent boy and a 21-year-old man with Chiari I malformation and cervical syrinx compressing or tightening the cervico-medullary junction; (2) a 35-year-old man with ependymoma extending from the lower half of the fourth ventricle to C1/C2 junction and compressing this part of the medulla; and (3) a 16-year-old adolescent boy who was referred to the emergency department in severe distress because of IH, occurring as a result of a distal PICA aneurysm located on the floor of the lower triangle of the fourth ventricle.

RESULTS

Surgical decompression in all the cases was successful in withholding the hiccups.

CONCLUSION

The dorsal medullary area is not an unusual location for genesis of hiccup. When encountering a case of IH, appropriate CNS imaging studies should be included in the evaluation protocol.

Management of hiccups in the palliative care population

There are close to a hundred causes for hiccups, or singultus, the most common of which are gastrointestinal. Causes may be natural or drug induced, and the same agents that are used to treat hiccups may also induce them. Hiccups can be classified by their duration, as follows: up to 48 hours, acute; longer than 48 hours, persistent; and more than two months, intractable. Treatment options for hiccups can include both pharmacologic and nonpharmacologic agents. If the cause of hiccups can be identified, it is, of course, preferable to direct the treatment at that cause. However many times a cause cannot be identified; in this case, general measures or treatments should be instituted. Intractable hiccups can occur in the palliative care population. When they do, it can be extremely distressing and have a significant impact on quality of life. Pharmacologic approaches are often the most rational therapies for these patients. Baclofen seems to be a promising drug for use with both palliative care and perioperative patients, and using garabentin as an add-on to baclofen may also be a reasonable option to consider