Management of hiccups in palliative care patients

Abstract

Persistent hiccups are a frustrating experience for palliative care patients, and can have a profound impact on their quality of life. This article provides an evidence-based approach overview of the causes and treatment of this not infrequently debilitating condition for such patients, with a management algorithm. In situations where no readily reversible cause is identified, or where simple physical manoeuvres, such as breath holding have failed, a systematic approach is required. Hiccups can be broadly divided into central and peripheral types. These respond differently to pharmacological intervention. The drug of choice for central causes of persistent hiccups is baclofen, with metoclopramide recommended as the first choice for peripheral causes. Midazolam may be useful in cases of terminal illness. Interventional procedures such as vagal or phrenic nerve block or stimulation should be considered in patients who are refractory to medications. The management of persistent hiccups still presents an ongoing clinical challenge however, requiring further research on pathophysiology and treatment strategies. Multinational randomised controlled trials to evaluate and compare both current and new medications or procedures to better manage this difficult condition are suggested as a means of reaching this goal.

Midazolam: an essential palliative care drug

“…Midazolam may be useful in the management of hiccups in terminal illness. 97 Pruritis and biliary obstruction Prieto found the use of continuous infusion of midazolam to be effective in refractory pruritis associated with biliary obstruction. The original intent was to use midazolam for sedation given the refractory nature of the pruritis.…”

Comparison the Effects of Ephedrine and Lidocaine in Treatment of Intraoperative Hiccups in Gynecologic Surgery under Sedation

“…The other was a report of a patient, whose hiccup resolved after a lidocaine bolus followed by a continuous infusion. Interestingly, in two case reports, a combination regimen of intravenous lidocaine and carbamazepine was necessary for sufficient symptom control,[2122] paralleling our experience with ephedrine and lidocaine. The underlying mechanism by which lidocaine may stop hiccups remains unclear.…”

An overview of the use of drugs in palliative care settings worldwide

“…Midazolam can be also used in the management of dyspnoea and hiccup. However, morphine and metoclopramide are regarded as being first choice therapies of the symptomatic treatment of dyspnoea and hiccup, respectively [33].…”