Gabapentin Therapy of Hiccups

Hiccups: An Atypical Manifestation of Miliary Tuberculosis and Myocardial Ischemia

Hiccups are a benign, self-limiting condition caused by intermittent spasmodic contractions of the diaphragm. However, its persistence may be indicative of a more ominous underlying condition, and its manifestation is seen in myocardial ischemia/infarction and tuberculosis (TB). We present two unique cases where persistent hiccups lead to the diagnosis of miliary tuberculosis in one patient and myocardial infarction in the other. It stresses the importance that such a benign presentation may be a warning for a more sinister pathology and thus requires extensive work-up in high-risk and senior individuals.

Hiccups in patients with cancer: a multi-site, single-institution study of etiology, severity, complications, interventions, and outcomes

Background

To our knowledge, previous studies have not investigated hiccups in patients with cancer with detailed patient-level data with the goal of capturing a broad spectrum of hiccup symptomatology.

Methods

This multi-site, single institution study examined consecutive medical records to better understand hiccups in patients with cancer.

Results

A total of 320 patients are the focus of this report. The median age of patients when hiccups were first reported in the medical record was 63 years (range: 21, 97 years) with 284 (89%) men and 36 (11%) women. The most common diagnose was gastrointestinal cancer. Hiccups most frequently occurred daily, as seen in 194 patients (62%), and the most common duration was less than 1 week, as seen in 146 patients (47%). However, nine patients had had daily hiccups for greater than 6 weeks, and 5 had symptoms for years. Cited etiology was non-chemotherapy medications in 36 (11%) and cancer chemotherapy in 19 (6%). Complications occurred in approximately a third and included insomnia in 51 patients (16%); hospitalization or emergency department visit in 34 (11%); and musculoskeletal pain in 23 (7%). Baclofen was the single most prescribed agent for hiccup palliation, but 100 patients received more than one medication. Medical procedures, which included acupuncture, paracentesis, or phrenic nerve block, were performed in 5 patients. In 234 patients (73%), the medical record documented hiccup cessation.

Conclusions

Hiccups appear to be highly problematic in a small subset of patients with cancer with no well-defined palliative approaches.

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.

Acupuncture for cancer-related hiccups: Protocol for a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Hiccups are involuntary contractions of the diaphragm and intercostal muscles, which lead to sudden contractions of the glottis. CAM, such as acupuncture is commonly used and stimulation of the vagus nerve and interference with phrenic nerve conduction are also used to treat hiccups. However, there is little evidence on the effectiveness of acupuncture for cancer-related hiccups. We will plan to conduct a systematic review and meta-analysis of RCTs to evaluate the current evidence on the effects of acupuncture for cancer-related hiccups.

METHOD

The following databases will be searched: PubMed, the Cochrane Library, Wanfang Data, China National Knowledge Infrastructure (CNKI), SinoMed, VIP, Medline, Embase, and EI. Randomized controlled trials will be included to evaluate the effect and safety of acupuncture on cancer patients with hiccups. We will set standards for the curative effect on the basis of the standard of cure and improvement for clinical disease diagnoses. The risk of bias will be assessed by the Cochrane risk of bias tool. We will conduct a meta-analysis and sensitivity analysis, as well as a subgroup analysis if high heterogeneity is present, using Revman 5.3. We will use funnel plots to identify potential reporting biases. We will test asymmetry using Egger test. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) will be used to evaluate the quality of evidence.

RESULTS

This study will be to assess the effect and safety of acupuncture for cancer-related hiccups.

CONCLUSIONS

This study will assess the effect of acupuncture for cancer-related hiccups and provide reliable evidence for the choice of treatments.

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.

Anterior and posterior diaphragm kinesio taping for intractable hiccups after ischemic stroke: A case report

RATIONALE

Pathophysiologic mechanisms of the central nervous system, such as stroke, can be associated with intractable hiccups. Intractable hiccups can be associated with potentially fatal consequences, thus requiring safe management in an inpatient rehabilitation facility (IRF) setting with a multidisciplinary team approach to optimize mobility and feeding.

PATIENT CONCERNS

A 49-year-old male presented to the emergency department with complaints of vomiting and dizziness.

DIAGNOSES

Head computed tomography revealed moderate acute inferior cerebellar infarct in the territory of the posterior inferior cerebellar artery. He required a percutaneous endoscopic gastrostomy tube for feeding and developed severe intractable hiccups which he rated 7/10 on the hiccup assessment instrument (HAI) on IRF admission. Functional independence measure (FIM) score for transfers was 2 (maximum assist), walking was 1 (total assist), stairs were not attempted on IRF admit due to safety concerns, and feeding (eating) was 1 (total assist).

INTERVENTIONS

Anterior and posterior diaphragm kinesio taping was applied on day 6 of IRF physical therapy in an attempt to inhibit diaphragm spasm and intractable hiccups given that pharmacologic interventions had not been effective up to that point (Table 3).

OUTCOMES

The HAI decreased from 7/10 on day 6 of IRF physical therapy to 0/10 on day 8. The taping was reapplied every 3 to 5 days. On IRF day 9, his diet was advanced to a regular consistency with extra moisture and thin liquids. On day 21, hiccup severity remained 0/10 on the HAI, while FIM score for transfers was 4 (minimal assist), walking was 4 (minimal assist), stairs was 4 (minimal assist), and feeding (eating) was 7 (independent).

LESSONS

Diaphragm kinesio taping is a very effective treatment at reducing hiccup severity in a patient after ischemic stroke, while at the same time reducing burden of care for caregivers per FIM score improvement and improving diet to that of regular consistency with extra moisture and thin liquids.

Alpha2delta ligands, gabapentin, pregabalin and mirogabalin: a review of their clinical pharmacology and therapeutic use

INTRODUCTION

The first two alpha₂delta ligands - gabapentin (GBP) and pregabalin (PGB) - were initially synthesized as antiepileptics; however, they were later also found to be useful for the treatment of additional conditions. Areas covered: Relevant publications describing potential underlying mechanisms, clinical pharmacokinetics/pharmacokinetics, and clinical efficacy and safety of these drugs in various disease conditions were searched in PubMed and Scopus and included in this review. Expert commentary: GBP and PGB are effective for the treatment neuropathic pain, fibromyalgia and epilepsy; in addition, they may be useful for the reduction of postoperative pain. PGB is also effective for the treatment of generalized anxiety disorder and GBP for the treatment of restless legs syndrome. GBP may be considered a treatment option for pain associated with Guillain-Barré Syndrome and phantom limb and for the management of uremic pruritus. Mirogabalin (MGB), recently developed, is being investigated for the treatment of peripheral neuropathic pain and fibromyalgia, showing promising results in patients with diabetic peripheral neuropathy. Their most frequent adverse reactions are of neuropsychiatric nature and include fatigue, dizziness, sedation, somnolence, and ataxia; peripheral edema and weight gain are also frequently described. Pharmacokinetic interactions are scarce; however, pharmacodynamic interactions have been described in association with drugs with CNS-depressant effects.

Systemic review: the pathogenesis and pharmacological treatment of hiccups

BACKGROUND

Hiccups are familiar to everyone, but remain poorly understood. Acute hiccups can often be terminated by physical manoeuvres. In contrast, persistent and intractable hiccups that continue for days or months are rare, but can be distressing and difficult to treat.

AIM

To review the management of hiccups, including a systematic review of reported efficacy and safety of pharmacological treatments.

METHODS

Available articles were identified using three electronic databases in addition to hand searching of published articles. Inclusion criteria were any reports of pharmaceutical therapy of 'hiccup(s)', 'hiccough(s)' or 'singultus' in English or German.

RESULTS

Treatment of 341 patients with persistent or intractable hiccups was reported in 15 published studies. Management was most effective when directed at the underlying condition. An empirical trial of anti-reflux therapy may be appropriate. If the underlying cause is not known or not treatable, then a range of pharmacological agents may provide benefit; however, systematic review revealed no adequately powered, well-designed trials of treatment. The use of baclofen and metoclopramide are supported by small randomised, placebo-controlled trials. Observational data suggest that gabapentin and chlorpromazine are also effective. Baclofen and gabapentin are less likely than standard neuroleptic agents to cause side effects during long-term therapy.

CONCLUSIONS

This systematic review revealed no high quality data on which to base treatment recommendations. Based on limited efficacy and safety data, baclofen and gabapentin may be considered as first line therapy for persistent and intractable hiccups, with metoclopramide and chlorpromazine in reserve.

Use of non-opioid analgesics as adjuvants to opioid analgesia for cancer pain management in an inpatient palliative unit: does this improve pain control and reduce opioid requirements?

BACKGROUND

Cancer pain is complex, and despite the introduction of the WHO cancer pain ladder, few studies have looked at the prevalence of adjuvant medication use in an inpatient palliative medicine unit. In this study, we evaluate the use of adjuvant pain medications in patients admitted to an inpatient palliative care unit and whether their use affects pain scores or opiate dosing.

METHODS

In this retrospective observational study, patients admitted to the inpatient palliative care unit over a 3-month period with a diagnosis of cancer on opioid therapy were selected. Data pertaining to demographics, diagnosis, oral morphine dose equivalent of the opioid at the time of discharge, adjuvant analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs), and pain scores as reported by nurses and physicians were collected.

RESULTS

Seventy-seven patients were eligible over a 3-month period, out of which 65 (84 %) were taking an adjuvant medication. The most commonly prescribed adjuvant was gabapentin (70 %). Fifty-seven percent were taking more than one adjuvant. There were more women in the group receiving adjuvants (57 vs. 17%, p = 0.010). Those without adjuvants compared with those on adjuvants did not have worse pain scores on discharge as reported by physicians (0.8 ± 0.8 vs. 1.0 ± 0.7, p = 0.58) or nurses (2.0 ± 2.7 vs. 2.1 ± 2.6, p = 0.86). There was no difference in morphine equivalent doses of the opioid in both groups (median (min, max); 112 (58, 504) vs. 200 (30, 5,040)) at the time of discharge; 75-80 % of patients had improvement in pain scores as measured by a two-point reduction in numerical rating scale (NRS).

DISCUSSION

This study shows that adjuvant medications are commonly used for treating pain in patients with cancer. More than half of study population were on two adjuvants or an adjuvant plus NSAID along with an opioid. We did not demonstrate any benefit in terms of improved pain scores or opioid doses with adjuvants, but this could reflect confounding variables and physician choice. Larger prospective studies are needed to define the opioid-sparing effects of adjuvants.

CONCLUSION

Adjuvant agents are used in over 80 % of those treated for cancer pain.