Letters to the Editor

Remedies for Prolonged Hiccups

TABLE Causes of Hiccups Gastric distension Excessive food or alcohol intake Aerophagia Gastric insufflation Sudden changes in gastric temperature Ingestion of hot or cold foods Moving from a hot to a cold area or vice versa Toxins Tobacco use Alcohol intoxication Central nervous system Stroke Arteriovenous malformation Cerebral contusion or hematoma Temporal arteritis Encephalitis or meningitis Neurosyphilis Multiple sclerosis Hydrocephalus Neoplasm Head trauma Peripheral nervous system (secondary to irritation of vagus or phrenic nerves) Goiter Head and neck tumors Mediastinal or lung masses Information from Kolodzik PW, Eilers MA. Hiccups (singultus): review and approach to management. Ann Emerg Med 1991;20:565-73.

TO THE EDITOR: Hiccups are an annoyance to nearly everyone at one time or another. Fortunately, they are also usually self-limited and benign. It is unusual for persons to seek care for hiccups unless the episode is particularly prolonged. Prolonged hiccups, however, can be debilitating and may be a sign of serious underlying disease. Thus, when patients do present with hiccups for medical attention, it is important to evaluate for potentially serious underlying causes.

Hiccups are believed to be caused mainly by irritation of either the phrenic or vagus nerves anywhere along their paths.¹ Central nervous system diseases, toxins, drugs and metabolic abnormalities may also lead to hiccups. The accompanying table¹ lists some of the many diseases that have been reported to cause hiccups.

Hiccups lasting longer than two days are termed "persistent" and those lasting longer than one month are considered "intractable."¹ Intractable hiccups will frequently be a sign of underlying organic disease¹; therefore, obtaining a thorough history and performing a physical examination is important to evaluate for potentially serious causes. The most useful studies are probably a chest radiograph and an electrolyte panel. Further studies can be ordered based on findings from the history and physical examination.

Many pharmacologic and nonpharmacologic remedies have been used to try to abort hiccups. Medications that have been reported to be effective include chlorpromazine (Thorazine),^1,2 nifedipine (Procardia),³ haloperidol (Haldol),^1,4 phenytoin (Dilantin),¹ metoclopramide (Reglan),¹ baclofen (Lioresal)^1,5 and gabapentin (Neurontin).⁶ Surgical management has included such techniques as phrenic nerve interruption or placement of diaphragmatic pacemakers.¹ Stimulating the nasopharynx with a rubber catheter and elevating the uvula with a cotton tip applicator or similar device have both been reported to be efficacious in the alleviation of hiccups.¹

Of any malady in medicine, hiccups probably have some of the most interesting home remedies. Perhaps the most well-known home remedy is breathing into a paper bag. This method (at least partly) relies on the observation that hiccups decreases as Pco₂ rises. Many of the home remedies either stimulate the nasopharynx or interrupt the normal respiratory cycle: holding one's breath, being frightened (gasping), swallowing sugar and sipping ice water. Drinking from the far side of a glass is one home remedy that is probably interesting to watch even it doesn't happen to work. We have also found that drinking a glass of water through a paper towel may be effective.

When you are seeing a patient with severe hiccups or (more commonly) when you or someone you know needs relief from hiccups, there are many (mostly anecdotal) effective methods you can try. And, for an interesting piece of trivia to impress the next harbinger of hiccups you meet, the medical term for hiccups is singultus.

ANTHONY J. VIERA, M.D.
STACEY A. SULLIVAN, M.D.
Naval Hospital Guam
PSC 490 Box NCTAMS
FPO AP 96538

The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or reflecting the views of the Navy Medical Department or the Naval Service at large.

REFERENCES

1. Kolodzik PW, Eilers MA. Hiccups (singultus): review and approach to management. Ann Emerg Med 1991;20:565-73.
2. Nathan MD, Leshner RT, Keller AP Jr. Intractable hiccups (singultus). Laryngoscope 1980;90(10 pt 1):1612-8.
3. Lipps DC, Jabbari B, Mitchell MH, Daigh JD Jr. Nifedipine for intractable hiccups. Neurology 1990;40(3 pt 1):531-2.
4. Ives TJ, Fleming MF, Weart CW, Bloch D. Treatment of intractable hiccups with intramuscular haloperidol. Am J Psychiatry 1985;142:1368-9.
5. Ramirez FC, Graham DY. Treatment of intractable hiccup with baclofen: results of a double-blind randomized, controlled, cross-over study. Am J Gastroenterology 1992;87:1789-91.
6. Petroianu G, Hein G, Stegmeier-Petroianu A, Begler W, Rufer R. Gabapentin "add-on therapy" for idiopathic chronic hiccup (ICH). J Clin Gastroenterology 2000;30:321-4.

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Assistance for Patients Who Cannot Afford Medications

TO THE EDITOR: The letters of responses to "Bending the Rules to Get a Medication"¹ focused on the illegality of changing the patient's name on a prescription in order to obtain insurance coverage for the medication, then presented alternatives for patients who couldn't afford their medications.

One letter stated the office nurse maintained a file of assistance programs associated with the pharmaceutical firms.

I believe it would be a great service to your readers to inform them of the following Web site that provides this file of assistance programs free of charge: http://www.NeedyMeds.com.

BRIAN S. ALPER, M.D.
University of Missouri­Columbia
Columbia, MO 65201

REFERENCE

1. Bending the rules to get a medication [Curbside Consultation]. Am Fam Physician 2000;61:1563-4.

Send letters to Jay Siwek, M.D., Editor, American Family Physician, 11400 Tomahawk Creek Parkway, Leawood, KS 66211-2672; fax:913-906-6080; e-mail: afplet@aafp.org. Please include your complete address, telephone number and fax number. Letters should be double-spaced, fewer than 500 words and limited to one table or figure and six references. Please submit a word count. Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter constitutes transfer of copyright to the American Academy of Family Physicians. The editors may edit letters to meet style and space requirements.

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Corrections*

Question 17 of the "Clinical Quiz" in the June 1, 2000, issue, pertaining to the article "Lichen Planus," was inaccurately stated. The question should ask, "Which of the following terms is/are typically used to describe lichen planus lesions?" The correct answers remain A and D.

The Clinical Quiz answer block in the April 1, 2001, issue, p. 1439, was incorrect.

*These corrections have been made to the online version of AFP. The links above will take you to the corrected items, which remain part of the online issues in which they were originally published.

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