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Medications Commonly Used to Treat Persistent or Intractable Hiccups by Plasil (Metoclopramide), Domperidone, Baclofen, and Chlorpromazine (Thorazine)

Updated: Jul 6

Medications for Treating Hiccups in Adults

Medication

Dosing + Formulation (NPO)

Dosing + Formulation (Non-NPO)

Plasil (Metoclopramide)

IV: 10 mg every 6-8 hours.

Oral/IM: 10-15 mg four times a day.

Domperidone

N/A

Oral: 10 mg every 4-8 hours.

Baclofen

N/A

Oral: 5 mg three times a day, max 80 mg/day.

Chlorpromazine (Thorazine)

IV/IM: 25-50 mg every 6-8 hours.

Oral: 25-50 mg three to four times a day.

Note: Extrapyramidal symptoms are a potential side effect for Plasil and Chlorpromazine and can be treated with Diphenhydramine.

 

Metoclopramide (Plasil): 10-15 mg orally up to four times a day or 10 mg IV every 6-8 hours. Chlorpromazine (Thorazine): 25-50 mg orally three to four times a day or 25-50 mg IV/IM every 6-8 hours.

 

Comprehensive Management of Hiccups in Clinical Practice

Introduction

Hiccups, medically known as singultus, are sudden, involuntary contractions of the diaphragm muscle. While most hiccups are self-limiting, persistent or intractable hiccups may require medical intervention. Below is a structured approach to managing hiccups using specific medications.

Medications for Treating Hiccups

  1. Plasil (Metoclopramide)

    • Mechanism of Action: Metoclopramide is a prokinetic and antiemetic agent that enhances gastric motility by antagonizing dopamine receptors and increasing acetylcholine release in the gastrointestinal tract.

    • Dosing:

      • Neonates: Oral/IV: 0.033-0.1 mg/kg/dose every 8 hours.

      • Infants and Children:

        • Gastroesophageal reflux: Oral/IM/IV: 0.1-0.15 mg/kg four times a day, max 10 mg/dose.

        • Postoperative nausea/vomiting: IV: 0.25 mg/kg every 6-8 hours, max 10 mg/dose.

      • Adults:

        • Gastroesophageal reflux: Oral/IM/IV: 10-15 mg four times a day.

        • Postoperative nausea/vomiting: IV: 10 mg every 6-8 hours.

    • Dosage Adjustments in Renal Impairment:

      • CrCl 40-50 ml/min: 75% of the normal dose.

      • CrCl 10-40 ml/min: 50% of the normal dose.

      • CrCl < 10 ml/min: 25-50% of the normal dose.

    • Formulations: Tablet 10 mg, Injection 5 mg/ml in 2 ml.

  2. Domperidone

    • Mechanism of Action: Domperidone is a dopamine antagonist that facilitates gastric emptying and reduces nausea.

    • Dosing:

      • Children: Oral: 0.2-0.4 mg/kg/dose every 4-8 hours.

      • Adults: Oral: 10 mg every 4-8 hours.

    • Formulations: Suspension 5 mg/5 ml, Tablet 10 mg.

Muscle Relaxants

  1. Baclofen (Lioresal)

    • Mechanism of Action: Baclofen acts as a GABA-B receptor agonist in the CNS, reducing muscle spasms, including those of the diaphragm.

    • Dosing:

      • Children (2-8 years): Start 2.5-10 mg/day divided every 8 hours, max 40 mg/day.

      • Children (8-12 years): Start 5-10 mg/day divided every 8 hours, max 60 mg/day.

      • ≥12 years and Adults: Start 5 mg three times a day, max 80 mg/day.

    • Dosage Adjustments in Renal Impairment:

      • CrCl 50-80 ml/min: 67% of the normal dose.

      • CrCl 30-50 ml/min: 50% of the normal dose.

      • CrCl < 30 ml/min: 33% of the normal dose.

    • Formulations: Tablet 10 mg.

  2. Orphenadrine

    • Mechanism of Action: Orphenadrine is an anticholinergic and muscle relaxant that can help reduce muscle spasms.

    • Dosing:

      • Adults: Oral: 100 mg twice a day.

    • Formulations: Tablet 100 mg.

  3. Tolperisone

    • Mechanism of Action: Tolperisone acts as a muscle relaxant with central action, reducing muscle tone and spasms.

    • Dosing:

      • Adults: Oral: 50-150 mg three times a day.

    • Formulations: Tablet 50 mg, 150 mg.

  4. Chlorpromazine (Thorazine)

    • Mechanism of Action: Chlorpromazine is a typical antipsychotic that primarily blocks dopamine (D2) receptors in the brain, alleviating hiccups.

    • Dosing:

      • Oral: 25-50 mg three to four times a day.

      • IV/IM: 25-50 mg every 6-8 hours.

    • Potential Side Effects:

      • Sedation, hypotension, extrapyramidal symptoms (e.g., dystonia, parkinsonism), anticholinergic effects (e.g., dry mouth, constipation).

    • Formulations: Tablet 25 mg, Injection 50 mg in 2 ml.

Additional Medications

  1. Gabapentin (Neurontin)

    • Mechanism of Action: Gabapentin is an anticonvulsant that modulates the release of excitatory neurotransmitters by binding to the alpha-2-delta subunit of voltage-gated calcium channels.

    • Dosing:

      • Initial: 300 mg orally on day one, then 300 mg twice on day two, and 300 mg three times on day three.

      • Maintenance: Typically 900-1800 mg/day in divided doses.

    • Potential Side Effects:

      • Dizziness: Common, especially at initiation.

      • Somnolence: Causes drowsiness.

      • Peripheral Edema: Swelling of extremities.

      • Ataxia: Lack of muscle coordination.

  2. Haloperidol (Haldol)

    • Mechanism of Action: Haloperidol is a typical antipsychotic that works by blocking D2 receptors in the brain. It is effective in treating hiccups through its central nervous system actions.

    • Dosing:

      • Oral: 1-2 mg two to three times a day.

      • IM: 2-5 mg every 4-8 hours as needed.

    • Potential Side Effects:

      • Extrapyramidal Symptoms: Includes muscle rigidity, tremors.

      • Sedation: Drowsiness and lethargy.

      • Hypotension: Low blood pressure.

      • Anticholinergic Effects: Dry mouth, constipation.

  3. Antacids and Proton Pump Inhibitors (PPIs)

    • Mechanism of Action: These medications reduce stomach acid production, which can help if hiccups are related to gastroesophageal reflux disease (GERD).

    • Common Antacids:

      • Magnesium hydroxide, aluminum hydroxide, calcium carbonate.

      • Dosing: 10-20 mL orally after meals and at bedtime.

    • Common PPIs:

      • Omeprazole, esomeprazole, lansoprazole.

      • Dosing: 20-40 mg orally once daily before a meal.

    • Potential Side Effects:

      • Antacids: Constipation (aluminum hydroxide), diarrhea (magnesium hydroxide).

      • PPIs: Headache, abdominal pain, potential risk of vitamin B12 deficiency with long-term use.

Clinical Considerations

  • Evaluation: Persistent hiccups lasting more than 48 hours should prompt evaluation for underlying causes, including gastrointestinal disorders, central nervous system issues, metabolic abnormalities, or drug-induced effects.

  • Tailoring Treatment: The choice of medication should be based on patient-specific factors, including the underlying cause of hiccups, comorbid conditions, and potential drug interactions.

  • Monitoring: Patients should be monitored for efficacy and side effects, and treatment should be adjusted as necessary.

 

Conclusion

Managing persistent or intractable hiccups can be challenging. By understanding the mechanisms, dosing, and potential side effects of available medications, healthcare providers can tailor treatment to each patient's specific needs. If first-line treatments are ineffective, consulting with a specialist may be necessary for further evaluation and management.

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