Chronic hiccups in palliative care

Hiccups in patients with palliative care needs can be triggered by metabolic failure (eg kidney, liver), diaphragmatic irritation (eg tumour, inflammation, gastric distension) or central nervous system lesions (eg medullary).

Causes of hiccups should be addressed but may not be reversible in all cases.

Many treatments have been tried for chronic hiccups, including drugs, acupuncture and hypnosis, though evidence is limited and most of the literature consists of case reports and small case seriesJeon, 2018. Management depends on the potential benefits and burdens of each intervention, and the patient’s prognosis, preferences and goals of care—see Principles of symptom management in palliative care.

Consider nonpharmacological measures for chronic hiccups, such as:

  • interrupting normal respiratory function (eg breath holding)
  • stimulating the nasopharynx or uvula (eg sipping cold water, swallowing a teaspoonful of sugar)
  • performing the Valsalva manoeuvre—this is best performed lying down
  • counteracting irritation of the diaphragm (eg pulling the knees to the chest, leaning forward to compress the chest).

For chronic hiccups that cause distress in a patient with palliative care needs (eg associated with pain, persistently disrupting sleep, activities or communication), consider a trial of one of the following drugsJeon, 2018Moretto, 2013:

1baclofen 5 mg orally, 3 times daily. Review response after 3 days baclofen

OR

2gabapentin 100 to 300 mg orally, daily, increasing at 3-day intervals as tolerated and according to response. Review response after 6 days. Maximum dose of 1200 mg daily in divided doses. For patients who are frail or older than 70 years, use the lower end of the dose range initially, titrate more slowly and do not exceed 900 mg daily in divided doses gabapentin

OR

2metoclopramide 10 mg orally, 8-hourly. Review response after 3 days metoclopramide

OR

3haloperidol 0.5 to 1 mg orally, daily. Review response after 3 days. haloperidol

Some drugs may be effective because of their sedative effects rather than any specific effect on the mechanisms of hiccup generation. If initial therapy was not effective, switch to another option.

If the patient responds to treatment and hiccups stop completely, consider withdrawing the drug. If hiccups continue, seek specialist advice.