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

Persistent hiccups due to aripiprazole: a case report and review of the literature

Introduction: Aripiprazole, a commonly prescribed antipsychotic, has been rarely associated with the onset of hiccups. This study aims to elucidate the prevalence, risk factors, and management of aripiprazole-induced hiccups. Methods: We report a case of aripiprazole-induced hiccups in a 32-year-old male diagnosed with Somatic Symptom Disorder per DSM-5 criteria.A comprehensive literature review was conducted, identifying 29 case reports of aripiprazole-induced hiccups. Patient demographics, dosage, onset and duration of hiccups, and management strategies were analyzed. Results: Aripiprazole-induced hiccups predominantly affected adolescents and middle-aged male patients (86.7%). The majority of hiccups developed within 1-2 days post-prescription (90.9%) and resolved within 1-4 days after discontinuation of aripiprazole. Discontinuation of aripiprazole was the most effective management strategy (51.7%). Co-administration with benzodiazepines was identified as a significant risk factor. Discussion: The findings suggest that clinicians should be vigilant for the onset of hiccups during the early stages of aripiprazole treatment, especially in male patients and those co-administered with benzodiazepines. Conclusion: Clinicians should be vigilant for hiccups during early aripiprazole treatment. Considering personality and psychological factors is crucial in managing hiccups in psychiatric patients.

Hiccups induced by aripiprazole combined with sertraline in an adolescent with olfactory reference disorder: A case report

BACKGROUND

Hiccup can cause significant distress to patients and affect medication compliance. Individuals with olfactory reference disorder (ORD) who might develop persistent hiccups when treated with a combination of antidepressant and antipsychotic, leading to significant distress and impairment.

CASE SUMMARY

We report a rare case of an adolescent with ORD who was treated with aripiprazole combined with sertraline and who began to hiccup persistently after 6 days on this treatment. He stopped hiccupping after the aripiprazole had been suspended for 12 h. After discharge, the patient continued on sertraline alone and reported no hiccupping at 1-month follow-up.

CONCLUSION

Clinicians should consider that the combination of aripiprazole and sertraline can induce hiccups during the acute administration period in adolescents with ORD.

Analysis of Factors Associated with Hiccups Using the FAERS Database

In this study, we used the large number of cases in the FDA adverse-event reporting system (FAERS) database to investigate risk factors for drug-induced hiccups and to explore the relationship between hiccups and gender. From 11,810,863 adverse drug reactions reported between the first quarter of 2004 and the first quarter of 2020, we extracted only those in which side effects occurred between the beginning and end of drug administration. Our sample included 1454 adverse reactions for hiccups, with 1159 involving males and 257 involving females (the gender in 38 reports was unknown). We performed univariate analyses of the presence or absence of hiccups for each drug and performed multivariate analysis by adding patient information. The multivariate analysis showed nicotine products to be key suspect drugs for both men and women. For males, the risk factors for hiccups included older age, lower body weight, nicotine, and 14 other drugs. For females, only nicotine and three other drugs were extracted as independent risk factors. Using FAERS, we were thus able to extract new suspect drugs for drug-induced hiccups. Furthermore, this is the first report of a gender-specific analysis of risk factors for hiccups that provides novel insights into drug-induced hiccups, and it suggests that the mechanism responsible is strongly related to gender. Thus, this study can contribute to elucidating the mechanism underlying this phenomenon.

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.

Hiccups in an Adult Case with Schizophrenia due to Aripiprazole: A Case Report

Neurotransmitters and neuroreceptors involved in the pathophysiology of hiccups are not well defined. However, dopamine and serotonin are reported to have roles in activating hiccups, and recent case reports suggest that some psychopharmacologic medications -such as antipsychotics- may trigger hiccups in many cases. Our case describes the activation of hiccups in a young male with schizophrenia while being treated with aripiprazole. The patient was switched from risperidone to aripiprazole due to excessive sedation, hiccups started within 48 hours of initiation of treatment with aripiprazole at a dosage of 15 mg/day, and no change in the hiccups was observed despite a dose reduction. Discontinuation of aripiprazole treatment resulted in complete relief from hiccups. This case report shows that antipsychotics may trigger hiccups.

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.

Persistent hiccups due to aripiprazole in an adolescent with obsessive compulsive disorder responding to dose reduction and rechallenge

Our case involves persistent hiccup arising in an adolescent with obsessive compulsive disorder (OCD) who was using aripiprazole as an augmentation to fluoxetine and whose hiccups remitted with dose reduction and rechallenge. Treatment suggested that aripiprazole might lead to hiccups. Antipsychotics are also used for the treatment of hiccups, but recent case reports suggest that they cause hiccups as well. Within 12 h of taking 5 mg aripiprazole, the 13-year-old girl began having continuous hiccups, which lasted for 3–4 h. The hiccups resolved when the dose of aripiprazole was reduced to 2.5 mg. To achieve augmentation, aripiprazole was replaced with risperidone 0.5 mg/day for 1 month, but excess sedation was observed. As a result, aripiprazole was restarted at a dose of 2.5 mg/day, and 1 week later, it was increased to 5 mg/every other day. No hiccups were observed.

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.

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.