Pharmacotherapy/Treatment Of Hiccup

Hiccup (scientific name is singultus, synchronous diaphragmatic flutter, SDF) are involuntary repetitive contraction of the diaphragm. The diaphragm is the muscles that separate the chest from the abdomen. It assists in breathing. Hiccup occurs when there is simultaneous closure of the diaphragm and the vocal cord. This put pressure in the vocal cord leading to a hic sound. Some call it hiccough.

There is no known benefit of hiccup unlike cough. Often, it affects a single diaphragm and not the two. It affects the left diaphragm more (80 percent). Hiccups occur more in the evening.

Hiccup remedy

Hiccups can last a few minutes to months. It affects people all over the world with episodes more in children. Children spend about 2.5 percent of their time hiccuping. Episodes reduce in adulthood. Affects more males than females. Females have a peak period during their cycle when it occurs.

Most hiccups go on their own. They do not require medical intervention. They hardly cause complications.

Causes Of Hiccup

For many years, scientists have tried to figure out what is the cause. It was just some years ago that they started to get results.

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Simple day to day activities like eating large meals, drinking carbonated beverages or sudden excitement (stress or joy) have been shown to trigger it. Swallowing air when chewing gum and extreme change in environment temperature can be the cause. Also, it can be a symptom of an underlying health condition.

Underlying Health Condition

1.  Nerve damage or irritation: when the vagus or phrenic nerve is damaged or irritated, hiccups may result. These nerves serve the diaphragm muscles. Causes of these damage or irritation include touching the eardrum, tumor, cyst or goitre at the neck, gastroesophageal reflux disease (GERD), sore throat or laryngitis.

2. Central nervous system (CNS): any form of damage to the CNS can disrupt normal control of hiccup reflex. Damage can arise from infection, trauma, tumor, etc. Examples of disease conditions known to affect the hiccup reflex are encephalitis, meningitis, multiple sclerosis, stroke and traumatic brain injury.

3. Metabolic disorders and drugs: there are some conditions that affect metabolic processes in the body. They have been shown to trigger hiccups. They include alcohol consumption, diabetes, electrolyte imbalance and kidney disease. Now, some drugs have the same effect which include benzodiazepine (anesthesia), short acting barbiturates, steroids (dexamethasone) and tranquilizers, donepezil and alpha methyldopa.

4. Medical procedure: surgery, catheter inserted into the mouth to access the heart muscles, bronchoscopy, tracheostomy and esophageal stent are some medical procedures that are known to trigger hiccups.

Types Of Hiccup

1. Acute or bout hiccup: this is a hiccup that is short and does not last for a long time. Just a few seconds to a few hours.

2. Persistent or protracted hiccup: when hiccup persists for more than 48 hours, it is called persistent hiccup.

3. Intractable hiccup: when hiccup prolong up to 2 months or more, it is called intractable hiccup.

Risk Factors

1. Surgery

2. Emotional issues

3. Mental illness

4. Men

Complication

1. Hiccups affect ability to eat resulting in poor eating habits. This can lead to weight loss and dehydration

2. Hiccup can interfere with quality sleep

3. Speech is altered

4. Poor wound healing after sleep

Diagnosis

There is no direct test for hiccup. Diagnosis is checking for underlying health conditions. For example, a medical doctor may perform neurological examination to check for balance and coordination, muscle strength, tone and reflex, skin and sense of touch test. Others are Blood sugar test, kidney test and presence of infection.

1. Fluoroscopy of diaphragm movement

2. Chest x-ray

3. Computer topography (CT) scan of the heart, thorax and abdomen

4. Magnetic resonance imaging (MRI) to study abdominal anatomy

5. Endoscopy

6. Bronchoscopy

7. Esophageal acid perfusion test

Pharmacotherapy/Treatment Of Hiccup

I grew up with the belief that hiccups have no cure. This was because a book by queens premier said so. I read a story in one of the brighter grammar where a man came to a chemist to get drugs for hiccups. The chemist man asks the other man to bend over. He hit the man hard on the back in an attempt to cure the hiccup. The man got angry and said he is not the one with the hiccup. So the chemist man told him that there is no cure. I don't know if I got that storyline perfectly but it sounds like that.

That idea that hiccups have no cure stayed with me for years. But not until recently when some patients started getting better with some drugs.

Hiccups caused by an underlying condition can be treated by treating the underlying condition. Hiccups lasting more than 2 days will require medical intervention.  The first choice of drugs are muscle relaxants like orphenadrine or baclofen. They relax the muscles of the diaphragm. Baclofen can be taken orally or intrathecal (into the spinal cord).

5mg of baclofen can be given 3 times a day for 3 days after which the dose is increased to 20mg 3 times a day for 3 days. The remaining 3 days can be given 25mg 3 times a day. Maintenance dose depends on individual response. Maximum daily dose should not exceed 80mg per day.

The injection is given 50mcg in 1ml over one minute. The patient is observed for 4-8 hours. The next dose can be given 24 hours later. 75mcg in 1.5ml with the same hours of observation. The last dose is given as 100mcg in 2ml. In both cases, olanzapine can be added to improve outcome.

Other drugs have been shown to work. Funny enough, they are different classes for different indications. For example, we have chlorpromazine and metoclopramide that have shown very good results. Where metoclopramide is a drug used to treat nausea and vomiting, chlorpromazine is an antipsychotic agent. Totally different class of drugs.

Chlorpromazine is given 25-50mg intravenously or intramuscularly achieving 80 percent cure rate. Metoclopramide dose is 10mg every 8 hours. An experiment was conducted where metoclopramide and a proton pump inhibitor were given together. The result came out good.

Here is a list of drugs that have worked for treating Hiccup.

1. Sedative e.g morphine, ketamine (is used during surgery given 0.4mg/kg which is one fifth anesthesia dose), chloral hydrate

2. Antihistamine e.g benadryl

3. Antihypertensive e.g nifedipine

4. Antidepressants e.g amitriptyline, haloperidol

5. Antihypertensive e.g ephedrine

6. Anticonvulsant e.g gabapentin, phenytoin, valproic acid, carbamazepine

7. Fat burner e.g phenadrine

8. CNS stimulant e.g methylphenidate, amphetamine

9. Respiratory stimulant e.g nikethamide

10. Antiviral and anti parkinsonism e.g amantadine

11. Anticholinesterase e.g edrophonium injection

12. Local anesthesia e.g lidocaine (1mg/kg IV given 2mg/min to cancer patient)

When drugs fail to resolve it, a surgical implant is used. It is a small battery operated device that delivers mild electrical impulses to the vagus nerve. Another medical procedure is nasogastric intubation. This involves inserting a tube through the nose into the stomach.

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Stopping some of the triggers can slow progression and result in healing. For example, dexamethasone should be swapped with methylprednisolone.

Home Remedies

Some mothers put a piece of thread on the head of babies with hiccups. Now that is superstition as it does not work. Breathing into a paper bag sounds ridiculous but widely accepted. However, gargling with ice water, holding breath, eating small bits of food and avoiding large meals,  avoiding carbonated beverages or food with gas have somehow resolved it. A teaspoon of granulated sugar, gastric lavage, carotid sinus massage and pulling on the tongue are also some home remedies. Holding one's breath and then exhaling very slowly, holding the nose, sucking on hard candy, drinking water from the far side of a glass, biting on a lemon, swallowing hard crusts of bread, sneezing, peeling onions, bending over so that the head is lower than the chest, surprising or frightening the person with hiccups, slapping the person with hiccups on the back, the list is just long. Acupuncture is a method accepted by some countries. All these are different remedies gotten from different countries over the years.