Recurrent Persistent Hiccups on Opioid Treatment: A Case Report and Literature Review

Abstract

Hiccups are a rare but potentially debilitating side effect of opioid treatment, with only a handful of reported cases in the medical literature. the pathophysiological mechanism linking opioids and hiccups is unknown, and a lack of evidence exists concerning the optimal management of the condition. We report on a 64-year-old man diagnosed with advanced renal cancer and painful osteolytic metastases, presenting persistent hiccups while on opioid treatment. Hiccups recurred after multiple challenges with codeine, morphine and hydromorphone on separate occasions. Hiccups ceased only after opioid discontinuation, although various pharmacological treatments were tried to shorten the duration of hiccups. eventually, fentanyl was introduced and was well tolerated by the patient, without any recurrence of hiccups. the chronological correlation between opioid initiation and the onset of hiccups, as well as opioid discontinuation and the termination of hiccups leads to the conclusion that a causal role of codeine, morphine and hydromorphone in this occurrence is likely. Individual susceptibility probably plays a central role in the development of opioid-related hiccups. opioid rotation is a promising strategy in the management of opioid-related hiccups, particularly when the mere discontinuation of the opioid is not a viable option, such as in the oncology and palliative care field.

An Unusual Cause of Intractable Hiccups

“…18 Steroids, opioids, and benzodiazepines can also lead to hiccups. [19][20][21] Steroids can directly stimulate the reflex arc; benzodiazepines can directly stimulate the inspiratory muscles; and opioids can elicit hiccups by an unknown mechanism. [19][20][21] An unremarkable brain and cervical spine MRI scan ruled out lesions affecting our patient's central processing unit and afferent-efferent pathways in the cervical region.…”

“… 18 Steroids, opioids, and benzodiazepines can also lead to hiccups. 19 – 21 Steroids can directly stimulate the reflex arc; benzodiazepines can directly stimulate the inspiratory muscles; and opioids can elicit hiccups by an unknown mechanism. 19 – 21 …”