Hiccup--a side-effect of pulse therapy

Persistent hiccups after interventional pain procedures: a case series and review

Interventional spine procedures are nonsurgical interventions that are commonly used to treat acute and chronic pain. These procedures generally are considered to be safe, but patients may experience transient and minor complications. Hiccups previously have been reported in the pain management setting as a complication after lumbar and thoracic epidural steroid injections and an intrathecal morphine pump infusion. In this case series of 8 patients, we describe hiccups after various interventional procedures, including cervical and lumbar epidural steroid injections, facet joint injections, and sacroiliac joint injections. A comprehensive literature review of hiccups associated with interventional pain procedures is provided, along with the known pathophysiology, etiologies, and treatment options for hiccups. The objective of this case series presentation and literature review is to highlight the importance of recognizing hiccups as a potentially under-reported adverse reaction in the setting of various interventional spine procedures.

Severe hiccups during chemotherapy: corticosteroids the likely culprit

Hiccups generally are self-limiting and of short duration. Those lasting more than 48 h or recurring at frequent intervals are termed persistent. There are numerous causes of hiccups, with medications implicated only rarely. While hiccups are usually benign, severe attacks may lead to exhaustion, eating difficulties, and affect quality of life. We report a case of severe hiccups in a patient receiving chemotherapy (oxaliplatin, 5-fluorouracil, leucovorin) for metastatic colorectal cancer. Hiccups began on the day following chemotherapy and continued constantly for over 30 h until relief was obtained by sucking the juice of a fresh lemonade. A similar pattern occurred in the next two chemotherapy cycles. Dexamethasone had been prescribed as prophylaxis against emesis and this was considered a possible cause. Withholding dexamethasone in the next cycle led to elimination of hiccups without having an impact on control of nausea and vomiting. A number of case reports have linked corticosteroids, particularly dexamethasone, to the occurrence of hiccups. Antineoplastic agents have occasionally been reported as causing hiccups; however, in most of these cases, corticosteroids, as part of the treatment protocol or as antiemetics, may have been a more likely cause. This case serves an as important reminder that adverse effects appearing during chemotherapy may not necessarily be due to antineoplastic agents. In the case of hiccups, oncology health professionals should review all medications and non drug-related factors before assigning causality. J Oncol Pharm Practice (2009) 15: 233—236.

Cisplatin-related hiccups: male predominance, induction by dexamethasone, and protection against nausea and vomiting

Dexamethasone is likely to play a role in the etiology of hiccups in patients receiving cisplatin-based regimens. Two hundred seventy-seven patients received three doses of ondansetron 8mg intravenously (IV) at 4hour intervals plus dexamethasone 20mg IV from the start of chemotherapy, followed by dexamethasone 5mg IV every 12hours, until chemotherapy was complete. Hiccups were observed in 114 (41.2%) patients, of whom 97.4% were men. Nausea and vomiting showed inverse correlations with hiccups (P < 0.0001 and P = 0.001, respectively). In 73 patients who experienced hiccups but lacked nausea/vomiting (H+N/V-), we discontinued dexamethasone in subsequent cycles. Sixty-six patients (90.4%) ceased hiccuping, but complete protection rates of nausea and vomiting decreased to 63% and 74%, respectively. For patients who experienced both hiccups and nausea/vomiting, the onset of nausea/vomiting usually was delayed to Day 3 or 4 and began after the cessation of hiccups. We conclude that cisplatin-related hiccups are predominant in males, dexamethasone-induced, and associated with protection against nausea/vomiting.

Persistent Hiccups Associated With Intravenous Corticosteroid Therapy

Singulata, commonly known as hiccups, have many causes and are most often idiopathic and short-lived. Occasionally, hiccups can be persistent and becoming quite bothersome, distracting, and even disabling. Many medications have been implicated as a cause of hiccups. Although uncommon, corticosteroids and benzodiazepines are 2 classes of drugs most frequently associated with the development of hiccups. The following case series describes 5 patients with intravenous corticosteroid-associated hiccups reported to our adverse drug reaction reporting system between January 1998 and December 2000. Physicians using intravenous corticosteroids should be aware of this potential complication.

Persistent hiccup associated with thoracic epidural injection

Epidural steroid injections are commonly used to treat lumbosacral radicular and discogenic pain. When used in this manner, these agents can cause minor, transient systemic side effects and rarely result in any serious complications. Because adverse reactions are uncommon and transient, epidural injections are considered a safe therapeutic intervention. We describe the first case of persistent hiccups as a consequence of a thoracic epidural steroid injection in a patient with thoracic discogenic pain.

Pulse glucocorticoids

High-dose intravenous (i.v.) methylprednisolone has been used therapeutically in a number of medical fields to avoid the complications and side effects of long-term glucocorticoid (GC) therapy and because of the perception that high-dose i.v. methylprednisolone may have "special" therapeutic effects. It is possible that aggressive early therapy with GCs allows for a more rapid taper of GCs and therefore prevents some of the dose-related side effects associated with long-term use. Some of the neurologic and rheumatologic literature related to multiple sclerosis and lupus nephritis suggest that i.v. methylprednisolone has therapeutic effects that are different from those of conventional doses of oral prednisone. There is still considerable debate about this in nondermatologic fields, and extrapolation of the role of pulse i.v. methylprednisolone to dermatologic disease, where trials are lacking, is difficult. Given this subset of possible candidates of this therapy as suggested by anecdotal reports, there is at least a rationale for considering the use of this modality in a subset of patients.

Hiccups with high dose dexamethasone administration: a case report

BACKGROUND

A 59-year-old male developed intractable hiccups during monthly therapy with high dose dexamethasone for multiple myeloma. Hiccups would begin hours after his first dose and continue over the 4 days of therapy. He sought assistance after his attempt at home remedies failed and the hiccups became exhausting.

METHODS

The strong temporal relation between dexamethasone administration and the occurrence of hiccups indicated that dexamethasone was the cause of the patient's hiccups. Because he was responding to dexamethasone, the decision was made to continue therapy and to relieve his hiccups with metoclopramide.

RESULTS

Low dose oral metoclopramide allowed the patient to continue therapy without a recurrence of the hiccups.

CONCLUSIONS

Dexamethasone administration can result in intractable hiccups that persist for the duration of therapy. Low dose oral metoclopramide may prevent hiccups in patients in whom the discontinuation of dexamethasone therapy is not appropriate.

Drug-induced hiccups

Pharmacotherapeutic agents are uncommonly associated with hiccups. Corticosteroids and benzodiazepines have been the drug classes mentioned most frequently in the literature as being associated with the development of hiccups. However, by using a strict criterion, there is currently insufficient evidence for any drug to be considered causative in the etiology of hiccups.