Persistent Hiccups During Rehabilitation Hospitalization: Three Case Reports and Review of the Literature

Hydrocortisone Therapy in Post-Stroke Management of Persistent Hiccups: A Case Report

Hiccups, also known as singultus, are involuntary spasms of the diaphragm muscle followed by laryngeal closure involving a reflex arc. It is a relatively common phenomenon, usually transient and self-limiting. However, in medical settings, it could be much more serious and is often a sign of underlying pathology. When hiccups last for over 48 hours, they are referred to as persistent hiccups, and if they persist for more than a month, they are known as intractable hiccups. Current pharmacologic treatment of persistent or intractable hiccups mainly includes antidopaminergic drugs, which specifically antagonize the dopamine D2 receptor. Here, we present the case of a 54-year-old gentleman who was admitted under our care with a posterior circulation stroke specifically affecting the medulla. He was symptomatic with severe, persistent hiccups interfering with sleep and oral intake and unresponsive to all standard medications. After nearly two weeks, a trial of hydrocortisone was given, to which he responded dramatically. To the best of our knowledge, this is the only case of hiccups that has been successfully treated with hydrocortisone. The remarkable improvement seen in our patient when treated with hydrocortisone suggests hydrocortisone could be a useful agent in post-stroke hiccups that are unresponsive to traditional treatment for hiccups.

Treatment of hiccups in stroke rehabilitation with gabapentin: A case series and focused clinical review

BACKGROUND

Persistent and intractable hiccups have a major impact on quality of life and can be a barrier to stroke rehabilitation. The first-line treatment for intractable hiccups, chlorpromazine, can have sedating effects, which may negatively affect rehabilitation participation. Gabapentin has been reported in several cases to be effective in hiccup treatment in both the general and post-stroke populations.

OBJECTIVE

To describe the use of gabapentin for treatment of persistent or intractable hiccups in post-stroke patients.

METHODS

Four cases were identified by clinicians for a retrospective review. A literature review was concurrently conducted.

RESULTS

This case series presents four patients with improvement or resolution of intractable hiccups on gabapentin in a stroke rehabilitation setting. Therapeutic dose ranged from 100 mg TID to 400 mg BID. Treatment duration ranged from 2 days to 5.5 weeks. Adjuncts were used in three of the cases. A potential side effect was worsened confusion in one case.

CONCLUSION

Evidence on the use of gabapentin for persistent or intractable hiccups is limited. This case series expands on the current literature by examining and comparing the current literature to our cases and exploring issues related to dosing, titration, side effects, and adjuncts to gabapentin.

Persistent hiccups in cancer patient: a presentation of syndrome of inappropriate antidiuretic hormone induced hyponatremia

Hyponatremia is quite common in cancer patients, but the presentation as persistent hiccups is not common. Literature over hiccups development due to hyponatremia is quite scant. Hiccups are of various types, persistent hiccups are those that last more than 48 h and remains less than 1 month. Hiccups lasting more than 24 h require investigation for an underlying organic etiology, with hyponatremia included in the differential diagnosis. This paper discusses a carcinoma lip patient presented with the persistent hiccups and unconsciousness post-operatively. The patient was initially responded with trials of both metoclopramide and Ryle's tube insertion, but eventually, his hiccups resolved only after treatment of hyponatremia. Patient's clinical course and investigations suggest an etiology of syndrome of inappropriate antidiuretic hormone (SIADH) secretion behind the hyponatremia. Study suggested that SIADH linked hyponatremia should be considered in the differential diagnosis of cancer patients with refractory 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.

Management of intractable hiccups: an illustrative case and review

Often thought of as a benign and self-limited condition, hiccups can become persistent or intractable, and thus be associated with substantial morbidity and distress. In such cases, an underlying etiology is often present, and may be overlooked. Debilitating hiccups can present a major challenge to optimal symptom management. Various causes of protracted hiccups have been identified including metabolic abnormalities, central nervous system pathology, malignancy, medications, and disorders attributed to cardiac, pulmonary and gastrointestinal etiologies. We present a case of intractable hiccups in a patient with an advanced hematological malignancy and review specific therapies for the management of persistent hiccups.

Persistent hiccups with continuous intrathecal morphine infusion

OBJECTIVE

To report a case of hiccups secondary to intrathecal (IT) morphine infusion.

METHODS

Case report and discussion.

RESULTS

The hiccups in our patient resolved on substitution of IT morphine infusion with hydromorphone.

DISCUSSION

We report a case of a 44-year-old man who developed persistent hiccups with IT morphine infusion pump therapy. The hiccups persisted despite various nonpharmacological and pharmacological measures. The untoward symptom resolved after substitution of IT hydromorphone for IT morphine.

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.

Early complications of ischemic stroke

Patients with acute ischemic stroke are at high risk of neurologic and medical complications, such as space-occupying edema formation, hemorrhagic transformation of the infarct, epileptic seizures, depression, and venous thromboembolism. They should therefore be monitored closely for early detection of these complications. Care is best when the patient is admitted to a specialized stroke unit. The multidisciplinary approach provided by stroke units, including specialized medical, nursing, and remedial therapies, reduces the duration of hospitalization and improves functional outcome. For many complications, however, optimal treatment and its effect on functional outcome after stroke has not been established. Therefore, in addition to the ongoing acute intervention trials, well-designed, large randomized trials are needed to address the prevention and treatment of complications and their effect on functional outcome.

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.