TREATMENT APPROACHES FOR PERSISTENT AND INTRACTABLE HICCUPS: A SYSTEMATIC REVIEW AND RECOMMENDATIONS

Abstract

Background:

Hiccups, involuntary contractions of the diaphragm, are commonly benign but can become distressing when persistent or intractable. While acute hiccups are self-limiting, lasting only a few minutes, persistent cases lasting days or months pose challenges in management.

Objective:

To evaluate existing treatment modalities for persistent and intractable hiccups and propose evidence-based recommendations.

Methods:

A systematic review was conducted to assess the efficacy of various treatments for persistent and intractable hiccups. Studies were included if they reported on interventions targeting hiccups and provided measurable outcomes. The search encompassed randomized controlled trials, observational studies, and case reports.

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, a systematic review revealed no adequately powered, well-designed trials of treatment. Small randomized, placebo-controlled trials support the use of baclofen and metoclopramide. The review identified a scarcity of adequately powered, well-designed trials on hiccup management. Empirical treatment targeting underlying causes, such as gastroesophageal reflux disease (GERD), was recommended if evident. Pharmacological interventions targeting dopaminergic and GABAergic receptors, such as baclofen and metoclopramide, showed promise in small randomized, placebo-controlled trials. Observational studies also suggested efficacy for Gabapentin and chlorpromazine, although associated side effects warrant caution.

Conclusion:

A treatment algorithm (Figure 3) is proposed based on available evidence, with baclofen as first-line therapy for persistent and intractable hiccups. Gabapentin may offer a safe and effective alternative, particularly for patients with central nervous system (CNS) involvement. However, long-term use of phenothiazines, including metoclopramide, is discouraged due to potential neurological and other adverse effects. Clinical decisions should align with recommendations from regulatory bodies and consider individual patient factors.