Topics in Palliative Medicine
Articles from the medical literature are digested, abstracted, and discussed by our AI hosts, with topics in symptom management, diagnosis, ethics and others.
Topics in Palliative Medicine
012 - Symptom Management: Gabapentin for Intractable Hiccups
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Hiccups, while often seen as a minor inconvenience, can become a significant health issue when they are persistent or intractable. This episode explores the science behind hiccups, their potential medical causes, and treatment options, particularly the use of gabapentin as an off-label solution.
• Discussion of the three types of hiccups: acute, persistent, and intractable
• Explanation of the hiccup reflex arc and its neurological basis
• Overview of the myriad causes of intractable hiccups, including central nervous system and psychological factors
• Introduction and definition of gabapentin, including its off-label use for hiccups
• Presentation of case studies demonstrating the efficacy of gabapentin
• Examination of potential side effects of gabapentin relative to other treatments
• Alternatives to gabapentin, including other medications and non-pharmacological home remedies
• Ethical considerations regarding off-label prescriptions and open communication with doctors
Thank you for your interest in Ethics in Palliative Medicine! Follow us at https://epionepalliative.com and on X: @PallCareEthics
Hey everyone, welcome back for another deep dive. Today we're going to be talking about something that's both weirdly fascinating and surprisingly complex Hiccups.
Speaker 2:Yeah.
Speaker 1:You specifically wanted to know more about gabapentin for hiccups, so we're going to be unpacking all of that with the help of this medical journal article. It's called Gabapentin for Intractable Hiccups in Palliative Care.
Speaker 2:OK.
Speaker 1:Published in the American Journal of Hospice and Palliative Medicine. Our expert is here to help us kind of break this down.
Speaker 2:Yeah, thanks for having me.
Speaker 1:You bet Okay, get this. The article starts by talking about different types of hiccups. Oh, Did you know that there are like acute hiccups, persistent hiccups and then wait for it, intractable hiccups?
Speaker 2:Intractable hiccups. That sounds pretty intense it does sound pretty intense, right?
Speaker 1:So acute hiccups are the ones we all know and occasionally love, you know. They last a few minutes, maybe an hour, and then they're gone as quickly as they came Right. Persistent hiccups stick around for more than two days, which already sounds pretty unpleasant, but intractable hiccups. Yeah, those are the ones that last for more than a month.
Speaker 2:A whole month.
Speaker 1:Yeah.
Speaker 2:I can see why someone would be searching for solutions.
Speaker 1:All right.
Speaker 2:Those are definitely the kind that could signal an underlying medical condition.
Speaker 1:Exactly so, before we get to the solutions, how about we do a little hiccups 101?
Speaker 2:Okay.
Speaker 1:This article talks about something called the hiccup reflex arc.
Speaker 2:Uh-huh.
Speaker 1:Can you break that down for us? What is that?
Speaker 2:So basically, imagine your brain accidentally sending a faulty signal that makes your diaphragm spasm.
Speaker 1:Okay.
Speaker 2:It's essentially a hiccup. It's kind of like a tiny electrical circuit going haywire, but instead of powering a light bulb it's causing that involuntary hic sound.
Speaker 1:So it's more than just a simple muscle spasm. Our brains are actually involved in this.
Speaker 2:Absolutely.
Speaker 1:Okay.
Speaker 2:Several nerves and specific areas of the brain play a role in this hiccup reflex arc. And here's a fun fact the article mentions that 80% of the time, hiccups affect the left side of the diaphragm.
Speaker 1:What.
Speaker 2:Yeah.
Speaker 1:More. Have you ever noticed if your hiccups feel lopsided? Now that you mention it, I don't know if I've ever paid attention.
Speaker 2:Yeah, it's something most people don't even think about.
Speaker 1:But OK. So we've got this complex reflex arc happening, but what triggers it in the first place? Why do we get hiccups?
Speaker 2:Well, for, like acute hiccups, it's often something simple Eating or drinking too quickly, gulping down a carbonated beverage, sudden change in temperature, even stress or excitement.
Speaker 1:Oh, okay.
Speaker 2:These things can irritate the nerves involved in that reflex arc and then set off a hiccup frenzy.
Speaker 1:That makes sense. But what about those intractable hiccups?
Speaker 2:Right.
Speaker 1:The ones that last for weeks on end. What's going on there?
Speaker 2:Well, here's where things get a little more complicated and a lot more interesting. The article points to over 100 of intractable hiccups.
Speaker 1:Over 100.
Speaker 2:Yeah.
Speaker 1:Wow, that's a lot of possibility.
Speaker 2:It really is. We're talking everything from issues in the central nervous system OK, like brain lesions, oh wow To problems with the esophagus, stomach, even psychological factors.
Speaker 1:Wait. Psychological factors mean like stress-induced hiccups, but lasting for a month.
Speaker 2:Exactly yeah, it's called psychogenic hiccups. The article also mentions medications as a potential culprit, with some like midazolam and dexamethasone being known to trigger hiccups. Oh, interesting yeah.
Speaker 1:So it's not always about that extra spicy burrito or that third glass of soda.
Speaker 2:Right.
Speaker 1:These intractable hiccups can be like a real medical mystery. Yeah, and they're probably more than just annoying. Could they actually be harmful?
Speaker 2:You're right to be concerned. The article mentions potential complications like weight loss, sleep disturbances, even pneumonia in severe cases.
Speaker 1:Oh, wow.
Speaker 2:So yeah, these hiccups can have a significant impact on someone's quality of life.
Speaker 1:Which brings us to the focus of this deep dive. Gabapentin is a possible treatment for those tough cases.
Speaker 2:Yeah, let's dig into that. Okay, yeah, sounds good. Before we jump into specifics, though, maybe we should quickly cover what gabapentin is.
Speaker 1:Yeah, great idea. I think that will help us understand how it could work for hiccups.
Speaker 2:Yeah, so gabapentin is a medication primarily used for seizures and nerve pain.
Speaker 1:And how does that apply to hiccups?
Speaker 2:Well, it's not. Fda approved specifically for hiccups.
Speaker 1:Okay.
Speaker 2:But doctors have been using it off-label with some encouraging results.
Speaker 1:Off-label. Can you explain what that means?
Speaker 2:Sure, off-label just means using a medication for a condition that's different from its original FDA-approved purpose. It's perfectly legal and happens quite frequently in medicine.
Speaker 1:Interesting. So doctors are using this seizure and nerve pain medication for hiccups.
Speaker 2:Yeah.
Speaker 1:How does that work?
Speaker 2:So instead of targeting the hiccups directly, gabapentin works by calming down the nerves that trigger them. Oh, okay, it essentially reduces those faulty signals from the brain that are causing the diaphragm to spasm.
Speaker 1:So you're basically giving those overactive nerves a chill pill.
Speaker 2:Yeah, that's a great way to put it.
Speaker 1:I like that Okay.
Speaker 2:And the article we're looking at goes deep into some case studies where gabapentin was used to treat intractable hiccups.
Speaker 1:Oh cool.
Speaker 2:I'm really interested to see how it worked out for those patients.
Speaker 1:Me too. Let's talk about those cases. Were there any where gabapentin actually helped?
Speaker 2:Oh yeah, there were some pretty remarkable cases.
Speaker 1:Okay.
Speaker 2:One patient had been struggling with hiccups for eight months.
Speaker 1:Eight months.
Speaker 2:Yeah, can you imagine?
Speaker 1:Oh, that's awful. I can't even imagine trying to go about daily life with like constant hiccups.
Speaker 2:It definitely sounds debilitating. Yeah, they had tried all sorts of treatments, but nothing seemed to work.
Speaker 1:Oh, wow.
Speaker 2:Then they started taking gabapentin Okay, and within a few weeks their hiccups significantly decreased. They weren't completely gone, but it was a huge improvement.
Speaker 1:Wow, that's impressive. Were there any other cases like that?
Speaker 2:There were.
Speaker 1:Oh cool.
Speaker 2:The researchers described three more patients who had been dealing with intractable hiccups for years, years Years, not just months.
Speaker 1:Wow.
Speaker 2:And in each case they experienced significant relief after starting gabapentin.
Speaker 1:That's really encouraging, but I'm curious did the article mention how long these patients continued taking gabapentin?
Speaker 2:Unfortunately, it didn't specify the duration of treatment.
Speaker 1:Oh, okay.
Speaker 2:But the fact that it helped people who had been suffering for so long is pretty amazing.
Speaker 1:It definitely makes you wonder if gabapentin could be a game changer for people with intractable hiccups.
Speaker 2:Right.
Speaker 1:Especially when you consider that some of the other treatments out there have pretty intense side effects.
Speaker 2:Yeah, definitely.
Speaker 1:Speaking of which, did the article mention any side effects for gabapentin? It did, okay.
Speaker 2:While gabapentin is generally considered safe, it can cause some drowsiness, dizziness and fatigue.
Speaker 1:So it's not a miracle cure.
Speaker 2:Right.
Speaker 1:It sounds like the side effects are relatively mild, especially compared to some of the alternatives. Yeah, didn't the article mention something about an antipsychotic being used for hiccups?
Speaker 2:It did Really. Chlorotramazine is actually the only drug officially approved for hiccups in the United States.
Speaker 1:An antipsychotic for hiccups? Yeah, that seems pretty extreme. Why would doctors prescribe that?
Speaker 2:It's typically reserved for severe cases of intractable hiccups that haven't responded to other treatments.
Speaker 1:Okay.
Speaker 2:But, as you might imagine, it comes with a greater risk of side effects like drowsiness, agitation and even a movement disorder called tardive dyskinesia.
Speaker 1:That sounds pretty serious. I can see why gabapentin would be a more appealing option for many people.
Speaker 2:Yeah.
Speaker 1:But I guess it all comes down to weighing the potential benefits against the risks, right? What about other alternatives? I think I saw baclofen on the list of medications mentioned in the article.
Speaker 2:You're right. Baclofen is another medication that's sometimes used for hiccups. Okay, it's primarily a muscle relaxant.
Speaker 1:Oh, okay.
Speaker 2:So the thinking is that it might help by relaxing the diaphragm. That makes sense. Did the article mention how effective it is? There's not a lot of research on baclofen specifically for hiccups. Oh really, one study. The article cited only involved four patients, Okay, which is too small of a sample size to draw any firm conclusions.
Speaker 1:Small sample size is the bane of research. But even if further research showed baclofen to be effective bane of research. But even if further research showed baclofen to be effective.
Speaker 2:Are there any downsides? Well, for one it can cause withdrawal symptoms if you stop taking it abruptly.
Speaker 1:Oh, oh.
Speaker 2:And it shares some similar side effects with chlorpromazine things like drowsiness, confusion and even a drop in blood pressure.
Speaker 1:So not ideal, especially if you're already dealing with a serious illness. Yeah, it seems like finding the right treatment for hiccups is a real balancing act, weighing the potential benefits against the potential downsides.
Speaker 2:Absolutely, and that's why the article emphasizes the importance of figuring out what's causing the hiccups in the first place. Right, it's not enough to just treat the symptom. You need to try to identify the underlying cause.
Speaker 1:It's like being a hiccup detective. Yeah, but with over 100 potential causes, that sounds like a pretty daunting task.
Speaker 2:It can be a challenge, yeah, but the article provides a good framework for approaching the diagnosis.
Speaker 1:Okay.
Speaker 2:It breaks down those 100 plus causes into different categories. We already talked about central nervous system issues like brain lesions.
Speaker 1:Right.
Speaker 2:But there's also diaphragmatic irritation Right. Anything that irritates the diaphragm, like pneumonia or even a surgical incision, can trigger hiccups.
Speaker 1:So even something as simple as a cough could set them off.
Speaker 2:Potentially, yes, interesting. Then you have problems originating in the chest, yeah, Like mediastinal or thoracic lesions, or even issues with the digestive system, like GERD or ulcers.
Speaker 1:Oh right.
Speaker 2:And of course, there are the psychogenic causes we discussed.
Speaker 1:Right.
Speaker 2:Stress, anxiety and even excitement can all play a role.
Speaker 1:It really is amazing how such a seemingly simple thing like a hiccup can have so many different origins.
Speaker 2:Yeah.
Speaker 1:I can see why getting a proper diagnosis is so important.
Speaker 2:It's crucial. Yeah, a doctor will consider your individual symptoms, medical history and any recent events that might have triggered the hiccups.
Speaker 1:OK.
Speaker 2:They may order tests like blood work, imaging studies or even an endoscopy to get a clearer picture.
Speaker 1:So it's about more than just prescribing a pill. It's about taking a holistic approach, looking at the whole person.
Speaker 2:Exactly. A holistic approach, looking at the whole person Exactly and sometimes simply addressing the underlying issue, can resolve the hiccups without the need for specific hiccup medications.
Speaker 1:That's reassuring to know. So if someone is experiencing persistent or intractable hiccups, what's the first step they should take?
Speaker 2:The first step is to talk to their doctor.
Speaker 1:Okay.
Speaker 2:It's important not to self-diagnose or self-treat, especially with hiccups that have been going on for a while.
Speaker 1:Right.
Speaker 2:A doctor can determine the severity of the situation and rule out any serious medical conditions.
Speaker 1:Sounds of solid advice, so we've covered the mechanics of hiccups.
Speaker 2:Yeah.
Speaker 1:The huge range of potential causes and delved into some treatment options, including gabapentin and clopramazine Right. What treatment options, including gabapentin and clopramazine Right? What other insights did the article offer?
Speaker 2:Well, it also mentioned some non-pharmacological approaches to managing hiccups. Okay, these are often the first line of defense for acute hiccups Right, and can sometimes be helpful for more persistent cases as well.
Speaker 1:By non-pharmacological you mean things people can try at home without medications, Exactly Okay.
Speaker 2:Think of it as the home remedy, route Right. Some of these methods aim to interrupt the hiccup reflex arc by stimulating the vagus nerve.
Speaker 1:Okay.
Speaker 2:For instance, holding your breath, drinking a glass of water quickly or gargling with ice water can sometimes do the trick.
Speaker 1:I've heard of us. My grandmother used to swear by swallowing a teaspoon of sugar. That's a classic one, yeah.
Speaker 2:And while there's no scientific evidence to back up these home remedies, they're generally safe to try and might provide some relief.
Speaker 1:So they're worth a shot. But if those simple techniques don't work or if the hiccups are really relentless, it's definitely time to seek professional help.
Speaker 2:Absolutely, and that's where the article's focus on gabapentin comes in.
Speaker 1:Right.
Speaker 2:While it's not a cure-all, it seems like a promising option for those really tough cases of intractable hiccups, especially for patients who haven't responded to other treatments or who can't tolerate the side effects of those other medications.
Speaker 1:So it's another tool in the toolbox for doctors to consider.
Speaker 2:Precisely and, with its relatively safe profile, it's definitely worth discussing with your doctor if you're struggling with persistent hiccups.
Speaker 1:It seems like we've really unpacked a lot about hiccups today.
Speaker 2:Yeah, we have.
Speaker 1:We've explored the intricate nerve pathways, the surprising number of potential causes and even dug into some potential solutions like gabapentin. This has been a fascinating deep dive.
Speaker 2:It has.
Speaker 1:But I have one last question before we wrap things up what happens when the solution itself raises ethical questions? We've been talking about gabapentin as a treatment for hiccups, but it's not actually FDA approved for that. Is it even ethical for doctors to be prescribing it this way?
Speaker 2:That's a great question and it's something a lot of people wonder about. Using medications off-label meaning for something other than their officially approved purpose is actually quite common in medicine.
Speaker 1:So it's not illegal or anything.
Speaker 2:Not at all. Doctors have the authority to prescribe medications in ways they believe will benefit their patients, even if it's for use that hasn't been specifically approved by the FDA.
Speaker 1:But it seems like there must be some risks involved. What are the potential downsides of off-label use?
Speaker 2:One concern is that there might not be as much research on the drug's effectiveness and safety for that particular off-label use.
Speaker 1:Okay.
Speaker 2:With gabapentin and hiccups, for example. We've got those promising case studies we discussed, but we still need more rigorous clinical trials to really understand how well it works and what the long-term effects might be.
Speaker 1:So it's kind of a gray area. There's the potential for benefit, but also a need for caution and careful consideration.
Speaker 2:Exactly, and that's why open communication between the doctor and patient is so important. The doctor should clearly explain the rationale for using the drug off-label, discuss the potential benefits and risks and talk about alternative treatment options, and the patient should always feel empowered to ask questions and express any concerns they have.
Speaker 1:It sounds like it's a partnership, not just a prescription.
Speaker 2:I like that. A partnership that's a great way to put it. It's about working together, doctor and patient, to make informed decisions and find the best course of treatment.
Speaker 1:Well said, Okay. So to sum things up for our listener, what are the key takeaways from all this? What do they need to remember about hiccups and gabapentin?
Speaker 2:Here are a few things to keep in mind. First, while hiccups are usually harmless, they can sometimes be a sign of an underlying medical condition, especially if they persist.
Speaker 1:Don't ignore those stubborn hiccups.
Speaker 2:Exactly. Second, if you're dealing with intractable hiccups, gabapentin has emerged as a potential treatment option. It's not a cure-all and it's prescribed off-label, but it's shown some real promise.
Speaker 1:And it seems to work by calming those overactive nerves that are triggering the hiccup.
Speaker 2:Right, but it's really important to have a conversation with your doctor about the potential benefits and risks and to explore other treatment options as well.
Speaker 1:It's all about finding the right treatment for each individual person.
Speaker 2:Couldn't agree more. And finally, don't underestimate the power of those simple home remedies. They might not always work, but they're usually safe to try and could provide some relief.
Speaker 1:So true. Well, I think we've successfully decoded the mystery of hiccups today, from the science behind them to the potential of gabapentin. This has been a fascinating deep dive.
Speaker 2:It has been Thanks for having me.
Speaker 1:Absolutely. Thanks for joining us for this deep dive into the fascinating world of hiccups. Until next time.
