Treating Intractable Hiccups in Advanced Cancer, Palliative Care Setting

What are some medications that can be used to treat intractable hiccups? — Name withheld on request

Intractable hiccups — also referred to as hiccoughs in the literature — can be especially problematic when treating patients with advanced cancer or in the palliative care setting. Multiple agents have been tried to treat this condition. Baclofen (Lioresal), chlorpromazine (Thorazine), and metoclopramide (Reglan) are the medications most frequently used in clinical practice for the treatment of intractable hiccups, with varying efficacy. Chlorpromazine is the only agent that is FDA-approved for the treatment of intractable hiccups. It and metoclopramide are thought to treat hiccups by modulating dopamine; metoclopramide also promotes gastric emptying, which may be helpful. Baclofen is thought to treat hiccups through its effects on the neurotransmitter GABA. Multiple other agents have been reported to have some effects in this setting, including anticonvulsants, proton pump inhibitors (PPIs), corticosteroids, nifedipine, and inhaled lidocaine; however, I generally begin treatment with baclofen, chlorpromazine, or metoclopramide as these agents have more supporting literature for this use.

I typically select an agent based on the patient’s other comorbidities and other medications they may be taking. For example, metoclopramide or baclofen may not be appropriate for some patients with renal dysfunction. Baclofen and chlorpromazine can cause sedation and should be used with caution in patients prone to falls. All of the above options can interact with other medications patients in this treatment setting may be receiving, and should be reviewed by a pharmacist to detect any potentially harmful drug interactions.