Hiccups as an adverse reaction to cancer chemotherapy

Persistent hiccups following thalamic hemorrhage: A case report

Persistent hiccups (lasting more than 48 hours) can cause physical and emotional distress. They can result in dehydration, exhaustion, malnutrition, insomnia, wound dehiscence, ventilatory desynchronization, and hemodynamic changes. Hiccups are thought to be due to a complex reflex arc involving peripheral nerves and central structures such as the brainstem, temporal lobe, basal ganglia, hypothalamus, and spinal cord levels C3-5. Medullary strokes, for instance, have been reported to cause hiccups. We report a patient with a thalamic bleed who developed persistent hiccups. A 56-year-old man was brought to the hospital in an unresponsive state. He was intubated for airway protection. CT brain showed a left thalamic hemorrhage with edema and mass effect on the 3rd ventricle, intraventricular extension of hemorrhage, and hydrocephalus. An external ventricular drain was placed successfully with adequate drainage. One week after admission, the patient developed persistent abdominal jerks. These jerks were occurring every 3-4 seconds and would last for hours with brief periods of remission. He was started on levetiracetam 1000 mg IV bid and then increased to 1500 mg IV BID without any improvement of symptoms. The patient was also placed on EEG which did not reveal any epileptiform abnormality but did show an EMG artifact. His electrolytes including sodium, and potassium, and corrected calcium levels were normal. He did not have any evidence of pneumonia or other infections. It was determined that these jerks were likely hiccups. Metoclopramide 10 mg IV was tried without any benefit. He was then started on Baclofen 10 mg PO TID which resulted in a significant improvement in hiccups. Our case suggests that thalamic lesions might also lead to persistent hiccups.

Hiccups in Cancer Patients Receiving Chemotherapy: A Cross-Sectional Study

CONTEXT

Hiccups are a symptom in cancer patients but it's less researched.

OBJECTIVES

The aimed to determine of prevalence of hiccups and treatment approach used in hiccup management in cancer patients receiving chemotherapy for nursing care.

METHODS

This study used a descriptive cross-sectional design with self-reported questionnaires and was conducted from November 2018-May 2019 in Turkey. For collection of the data, a Patient Information Form (sociodemographic and disease characteristics), and a Hiccups Evaluation Form were used for the patients.

RESULTS

Hiccups were observed in 37 (23%) of the 160 patients who met the criteria for inclusion in the study. The great majority of the patients suffering from hiccups were male (65.9%) and the type of cancer in the majority of these patients was gastrointestinal cancer (54.1%). It was determined that the duration of hiccups in 83.8% of patients observed with hiccups was between 0 and 48 hours, that the average severity of their hiccups was 3.81 ± 2.25 (0-10), and that hiccups in 59.5% of these patients was of low severity. It was found that only 10.8% of patients suffering from hiccups used pharmacological methods for relief and that 27% used nonpharmacological methods.

CONCLUSION

The results of the study showed that over one-fifth of cancer patients suffered from hiccups. This situation reveals that hiccups are an important symptom that needs to be carefully emphasised in oncology practice.

Frequency and Symptomatology of Hiccups in Patients With Cancer: Using an On-Line Medical Community to Better Understand the Patient Experience

BACKGROUND

Cancer patients are at risk for hiccups, but the incidence and impact on quality of life are unclear.

METHODS

A survey (modified from the Functional Living Index with the inclusion of qualitative elements) was developed and launched on an 80,000-member medical social media platform, Mayo Clinic Connect https://connect.mayoclinic.org/.

RESULTS

Among 213 respondents, 34 (16%; 95% CI: 11, 22%) reported "yes" that they had experienced hiccups with cancer therapy. Of those patients who reported hiccups, only 12 (35%) were men, and most were older than 50 years of age. Over 25% noted that hiccups occurred frequently around the time of cancer therapy; 30% described that hiccups interfered with their leisure or recreational activities; and over 15% described hiccups interfered with their ability to enjoy a meal. A few patients seemed to express frustration with hiccups with comments such as, "Totally uncontrollable," "It's extremely pain[ful] with throat cancer," and "Once I had them bad. Almost choked."

CONCLUSION

Hiccups occur in16% of patients who are receiving cancer therapy and, by our estimates and extrapolation, appear highly problematic in approximately 5%.

Prevalence and associated factors of orphan symptoms in advanced cancer patients: a multicenter observational study

PURPOSE

The aims of this study were to examine the prevalence of myoclonus, sweating, pruritus, hiccup, and vesical and rectal tenesmus, and to explore associated factors in patients with advanced cancer.

METHODS

This multicenter prospective cohort study was conducted in 23 inpatient hospices/palliative care units in Japan from January to December 2017. The prevalence and characteristics of each symptom were assessed on admission and in the 3 days before death. We selected factors that might influence the occurrence of each symptom and investigated the association.

RESULTS

A total of 1896 patients were enrolled. The prevalence of orphan symptoms rose from admission to the 3 days before death: myoclonus 1.3 to 5.3% (95% CI 0.9-1.9%/4.3-6.5%), sweating 1.8 to 4.1% (95% CI 1.3-2.6%/3.1-5.1%), hiccup 1.1 to 1.8% (95% CI 0.7-1.7%/1.2-2.6%), and tenesmus 0.7 to 0.9% (0.4-1.2%/0.5-1.5%). Prevalence of pruritus fell from 3.5 to 2.5% (95% CI 2.7-4.4%/1.8-3.4%). Sweating, pruritus, and hiccups persisted throughout the day in nearly half of the patients. Myoclonus was significantly associated with brain tumors, sweating with opioids and antipsychotics, pruritus with liver and biliary tract cancer, cholestasis and severe diabetes, hiccup with male gender, digestive tract obstruction, severe diabetes, and renal failure. Vesical tenesmus was associated with urinary cancer, antipsychotics, and anticholinergics and rectal tenesmus with pelvic cavity cancer.

CONCLUSION

We found that orphan symptoms occurred in 0.5-5.0% of patients, increased over time except for pruritus, and persisted in half of the patients.

Effect of Shakuyakukanzoto on Chemotherapy-Induced Hiccups in Patients with Lung Cancer

Objective

Shakuyakukanzoto, one of the traditional herbal medicines commonly used in North-East Asian countries, is known to be effective for muscle cramps. This retrospective study aimed to evaluate the effect of shakuyakukanzoto on chemotherapy-induced metoclopramide-uncontrolled hiccups.

Materials and Methods

We retrospectively investigated the medical records of all the consecutive patients with lung cancer who were prescribed with shakuyakukanzoto (Tsumura Co. Tokyo, Japan) for chemotherapy-induced hiccups in our hospital from September 2013 to November 2017. In the medical record from the initiation of shakuyakukanzoto until the start of the next chemotherapy, when there was description of "complete or partial disappearance of hiccups" after the prescription of shakuyakukanzoto, it was judged as a complete or partial response. A statement of "unchanged," no description of improvement, or exacerbation was judged as no change.

Results

Of the 49 chemotherapy courses in 15 patients with lung cancer, 93.9% had a "partial or complete" response within a few hours after the administration of shakuyakukanzoto. The effect of shakuyakukanzoto was observed irrespective of the pathological type of lung cancer, platinum-containing or non-platinum chemotherapy, and with or without other anti-hiccup drugs. No adverse event was observed.

Conclusion

Shakuyakukanzoto may offer an effective pharmacological approach to treat chemotherapy-induced metoclopramide-uncontrolled hiccups. Well-planned prospective studies will confirm our results.

Chronic Hiccups

PURPOSE OF REVIEW

Nearly 4000 patients will be admitted to hospital in the US this year for hiccups. Hiccups are controlled by a complex reflex arc between peripheral receptors and the brainstem. Any disruption along this pathway may produce hiccups. Typically, hiccups resolve spontaneously but in certain pathologies symptoms may persist. Persistent hiccups may be considered a sign of underlying pathology. The most common cause involves GERD.

RECENT FINDINGS

Based on etiologies, studies have shown that first-line therapy should use a proton pump inhibitor (PPI) and involve appropriate gastrointestinal consultation. If symptoms persist, other etiologies such as central causes need to be explored.

SUMMARY

We review the pathophysiology of hiccups including multiple causes and the appropriate work up for each. We review several studies examining new treatments, both pharmacological and interventional, that may help patients. Initial therapy should still involve a PPI but several new therapies may be beneficial.

Perspectives on the Medical, Quality of Life, and Economic Consequences of Hiccups

PURPOSE OF REVIEW

Singultus or hiccups (HU) is a common, usually temporary, event. Its potentially serious consequences are often overlooked. This review explores published evidence describing HU burden (clinical, economic, and quality of life [QoL] consequences) across patient populations.

RECENT FINDINGS

Literature review identified 81 articles (including 57 individual case reports). We extracted relevant information to better understand the burden of HU and to identify knowledge gaps for future study. HU are physiologic events that can complicate existing medical conditions and treatments regardless of duration. Relatively short episodes can have devastating consequences in patients who have pre-existing conditions. HU appear to impact physical and psychological health, diminish QoL, increase healthcare resource use, and increase costs. A better understanding of HU burden is needed.

Factors associated with dexamethasone-induced hiccups in cancer patients undergoing chemotherapy: A case control study

PURPOSE

The purpose of this study was to identify demographic, health- and cancer-related, and physiological factors associated with dexamethasone-induced intractable hiccups in cancer patients.

METHOD

This study adopted a retrospective case control design. The study subjects were 168 cancer patients admitted to a university hospital for chemotherapy between October 2011 and December 2016: 58 patients who experienced intractable hiccups while on dexamethasone (cases) and 110 matched patients who received dexamethasone but did not experience hiccups (controls). Data were collected from most recent medical records and included demographic, health- and cancer-related, and physiological factors.

RESULTS

Our findings demonstrated that the development of dexamethasone-induced hiccups was significantly associated with a male gender, a young age, overweight/obesity, the use of alkylating anticancer agents (particularly as the first anticancer drug), high levels of hemoglobin, serum creatinine, uric acid, and albumin, and an elevated body temperature.

CONCLUSIONS

Oncology nurses should be aware of influencing factors of dexamethasone-induced hiccups in cancer patients receiving chemotherapy. Our findings may provide evidence to design oncology nursing strategies that help maximize the benefits of chemotherapy in cancer patients.

Antiemetic Corticosteroid Rotation from Dexamethasone to Methylprednisolone to Prevent Dexamethasone-Induced Hiccup in Cancer Patients Treated with Chemotherapy: A Randomized, Single-Blind, Crossover Phase III Trial

BACKGROUND

To assess whether the rotation of dexamethasone to methylprednisolone decreases the intensity of dexamethasone-induced hiccup (DIH) in cancer patients treated with chemotherapy.

MATERIALS AND METHODS

Adult patients who experienced DIH within 3 days after the administration of dexamethasone as an antiemetic were screened. Eligible patients were randomly assigned to receive dexamethasone (n = 33) or methylprednisolone (n = 32) as an antiemetic (randomization phase). In the next cycle of chemotherapy, the dexamethasone group received methylprednisolone and vice versa in the methylprednisolone group (crossover phase). The primary endpoint was the difference in hiccup intensity as measured using the numeric rating scale (NRS) between two groups.

RESULTS

No female patients were enrolled, although the study did not exclude them. At the randomization phase, hiccup frequency was 28/33 (84.8%) in the dexamethasone group versus 20/32 (62.5%) in the methylprednisolone group (p = .04). Intensity of hiccup was significantly higher in the dexamethasone group than that in the methylprednisolone group (mean NRS, 3.5 vs. 1.4, p < .001). At the crossover phase, hiccup intensity was further decreased after the rotation of dexamethasone to methylprednisolone in the dexamethasone group (mean NRS, 3.5 to 0.9, p < .001), while it was increased by rotating methylprednisolone to dexamethasone in the methylprednisolone group (mean NRS, 1.4 to 3.3, p = .025). There were no differences in emesis intensity between the two groups at either the randomization or crossover phases. Clinicaltrials.gov identifier: NCT01974024.

CONCLUSION

Dexamethasone-induced hiccup is a male-predominant phenomenon that can be ameliorated by rotating dexamethasone to methylprednisolone without compromising the antiemetic efficacy.

IMPLICATIONS FOR PRACTICE

In this randomized, multicenter, phase III trial, hiccup intensity was significantly lower when the antiemetic corticosteroid was rotated from dexamethasone to methylprednisolone without a change in emesis intensity than that when dexamethasone was maintained. At the crossover phase, hiccup intensity was increased again if dexamethasone was readministered instead of methylprednisolone. The present study demonstrated that dexamethasone-induced hiccup can be improved by rotating from dexamethasone to methylprednisolone without compromising its antiemetic efficacy.

Gender Differences in Hiccup Patients: Analysis of Published Case Reports and Case-Control Studies

CONTEXT

Although sporadic male predominance in hiccup patients has been reported, the association between gender differences and triggering factors has rarely been evaluated in patients with hiccups.

OBJECTIVES

The aim of this study was to investigate whether gender differences exist in hiccup patients by analyzing all previously published hiccup literature containing gender and etiology information.

METHODS

Published literature on this topic was identified using a standardized search strategy in the PubMed, SCOPUS, and CINAHL electronic databases. The literature search included studies published from January 1990 to December 2013. Searches were limited to English-language publications. Of 476 identified studies, 318 studies were eligible including eight case-control studies that contained nonhiccup control groups. Triggering factors for hiccups were categorized into two types: central nervous system (CNS) and non-CNS causes. Odds ratios (ORs) were calculated for the eight case-control studies and event rates for the other studies by meta-analysis. In addition, gender differences and mean ages were analyzed for the case studies.

RESULTS

Pooled OR was 2.42 (95% confidence interval [CI] 1.40-4.17) with inclination for male predominance. Subgroup analysis by cause showed clear male predominance in the non-CNS type with OR of 11.72 (95% CI 3.16-43.50), whereas indistinct in the CNS type with OR of 1.74 (95% CI 0.95-3.16). Of the remaining 310 studies with 864 patients, previous findings were consistent. Male predominance was consistent in non-CNS (85.1%, 95% CI 78.2-90.2) and unknown origin (82.2%, 95% CI 75.8-87.2) patients, whereas mitigating the sex discrepancy in those with CNS origin (65.8%, 95% CI 53.1-76.5).

CONCLUSION

We demonstrated male predominance in hiccup patients. This gender difference for hiccups was more pronounced in patients with non-CNS causes, whereas indistinct in patients with CNS causes.

Transient hiccups associated with oral dexamethasone

Hiccups, or singulata (hiccup is singultus), are commonly experienced by most people at one time or another and are usually brief and self-limiting. Although pharmacotherapeutic agents are not generally considered causal in the etiology of hiccups, many clinicians empirically associate episodic hiccups in their patients as being drug induced. The two classes of drugs most often cited as causing hiccups are corticosteroids and benzodiazepines. This report involved a patient who was given preoperative dexamethasone and developed hiccups before anesthesia and surgery commenced. He at no time was in distress, and the surgical procedure was completed without complication. By the second postsurgical day his hiccups were resolved completely. Although the association may be anecdotal, many clinicians consider hiccups a potential side effect of steroid therapy, especially high doses of steroids. Of interest in this case is the relatively low dose of corticosteroid used, albeit apparently linked to his hiccups. Practitioners should be aware of this potential condition.

High dose of prokinetics for refractory hiccups after chemotherapy or the return to a simple drug

Hiccups in patients with cancer might be difficult to treat, impacting negatively on the quality of life. Many therapies are available, but they are usually started empirically, and often they are unsuccessful. We report a case of a man with metastatic colon cancer who after the first cycle of chemotherapy developed persistent hiccups refractory to neuroleptics and low dose of metoclopramide. After searching for the potential cause, a high dose of prokinetics was initiated in the hospital and his symptoms disappeared. This case shows how searching for potential causes helps start the right treatment immediately, and therefore it is relevant for the prompt relief from this bothersome symptom. So far, no cases reporting high doses of prokinetics to treat persistent hiccups after chemotherapy have been published. This option should be taken into account when developing hiccups and gastro-oesophageal reflux after chemotherapy, especially if low doses of prokinetics have already been tried.

Treatment of dexamethasone-induced hiccup in chemotherapy patients by methylprednisolone rotation

Dexamethasone-induced hiccup (DIH) is an underrecognized symptom in patients with cancer, and little information is available about its treatment. The aims of this study were to investigate the feasibility of methylprednisolone rotation as treatment and to confirm the male predominance among those with cancer who experienced DIH during chemotherapy. Methods. Persons with cancer who experienced hiccups during chemotherapy treatment and who were receiving treatment with dexamethasone were presumed to have DIH. The following algorithmic practice was implemented for antiemetic corticosteroid use: rotation from dexamethasone to methylprednisolone in the next cycle and dexamethasone re-administration in the second cycle of chemotherapy after recognition of hiccups to confirm DIH. All other antiemetics except corticosteroid remained unchanged. Patients (n = 40) were recruited from eight cancer centers in Korea from September 2012 to April 2013. Data were collected retrospectively. Results. Hiccup intensity (numeric rating scale [NRS]: 5.38 vs. 0.53) and duration (68.44 minutes vs. 1.79 minutes) were significantly decreased after rotation to methylprednisolone, while intensity of emesis was not increased (NRS: 2.63 vs. 2.08). Median dose of dexamethasone and methylprednisolone were 10 mg and 50 mg, respectively. Thirty-four (85%) of 40 patients showed complete resolution of hiccups after methylprednisolone rotation in the next cycle. Of these 34 patients, 25 (73.5%) had recurrence of hiccups after dexamethasone re-administration. Compared with baseline values, hiccup intensity (NRS: 5.24 vs. 2.44) and duration (66.43 minutes vs. 22.00 minutes) were significantly attenuated after dexamethasone re-administration. Of the 40 eligible patients, 38 (95%) were male. Conclusion. DIH during chemotherapy could be controlled without losing antiemetic potential by replacing dexamethasone with methylprednisolone. We also identified a male predominance of DIH. Further prospective studies are warranted.

Management of intractable hiccups: an illustrative case and review

Often thought of as a benign and self-limited condition, hiccups can become persistent or intractable, and thus be associated with substantial morbidity and distress. In such cases, an underlying etiology is often present, and may be overlooked. Debilitating hiccups can present a major challenge to optimal symptom management. Various causes of protracted hiccups have been identified including metabolic abnormalities, central nervous system pathology, malignancy, medications, and disorders attributed to cardiac, pulmonary and gastrointestinal etiologies. We present a case of intractable hiccups in a patient with an advanced hematological malignancy and review specific therapies for the management of persistent hiccups.

Gabapentin in the treatment of persistent hiccups in advanced malignancy

Hiccups are a distressing symptom in advanced malignancies in the setting of palliative care. A case of persistent hiccups treated with oral Gabapentin is presented to highlight the clinical and ethical dilemmas in patients with advanced malignancy. A 70-year-old male with non-small cell cancer of the lung with widespread metastases presented with persistent hiccups. The patient and family sought only symptom relief from home, without hospitalization or further investigations. The hiccups were dramatically relieved by oral Gabapentin, highlighting the recent reports that mention this molecule as being useful for hiccups. Gabapentin is a simple tool that may be utilized by palliative care physicians to relieve hiccups in advanced malignancies.

Sedation-associated hiccups in adults undergoing gastrointestinal endoscopy and colonoscopy

AIM: To investigate whether the incidence of hiccups in patients undergoing esophagogastroduodenoscopy (EGD) or same-day bidirectional endoscopy (EGD and colonoscopy; BDE) with sedation is different from those without sedation in terms of quantity, duration and typical onset time.

METHODS: Consecutive patients scheduled for elective EGD or same-day BDE at the gastrointestinal endoscopy unit or the health examination center were allocated to two groups: EGD without sedation (Group A) and BDE with sedation (Group B). The use of sedation was based on the patients’ request. Anesthesiologists participated in this study by administrating sedative drugs as usual. A single experienced gastroenterologist performed both the EGD and the colonoscopic examinations for all the patients. The incidence, duration and onset time of hiccups were measured in both groups. In addition, the association between clinical variables and hiccups were analyzed.

RESULTS: A total of 435 patients were enrolled in the study. The incidences of hiccups in the patients with and without sedation were significantly different (20.5% and 5.1%, respectively). The use of sedation for patients undergoing endoscopy was still significantly associated with an increased risk of hiccups (adjusted odds ratio: 8.79, P < 0.001) after adjustment. The incidence of hiccups in males under sedation was high (67.4%). The sedated patients who received 2 mg midazolam developed hiccups more frequently compared to those receiving 1 mg midazolam (P = 0.0028). The patients with the diagnosis of gastroesophageal reflux disease (GERD) were prone to develop hiccups (P = 0.018).

CONCLUSION: Male patients undergoing EGD or BDE with sedation are significantly more likely to suffer from hiccups compared to those without sedation. Midazolam was significantly associated with an increased risk of hiccups. Furthermore, patients with GERD are prone to develop hiccups.

Hiccup: mystery, nature and treatment

Hiccup is the sudden onset of erratic diaphragmatic and intercostal muscle contraction and immediately followed by laryngeal closure. The abrupt air rush into lungs elicits a "hic" sound. Hiccup is usually a self-limited disorder; however, when it is prolonged beyond 48 hours, it is considered persistent whereas episodes longer than 2 months are called intractable. A reflex arc involving peripheral phrenic, vagal and sympathetic pathways and central midbrain modulation is likely responsible for hiccup. Accordingly, any irritant in terms of physical/chemical factors, inflammation, neoplasia invading the arc leads to hiccups. The central causes of hiccup include stroke, space occupying lesions and injury etc, whereas peripheral causes include lesions along the arc such as tumors, myocardial ischemia, herpes infection, gastroesophageal reflux disease and applied instrumentations on human body etc. Besides, various drugs (eg, anti-parkinsonism drugs, anesthetic agents, steroids and chemotherapies etc) are the possible etiology. An effective treatment of persistent hiccup may be established upon the correct diagnosis of lesion responsible for the serious event. The pharmacotherapy of hiccup includes chlorpromazine, gabapentin, baclofen, serotonergic agonists, prokinetics and lidocaine. Non-pharmacological approaches such as nerve blockade, pacing, acupuncture and measures to hold breathing are also successful. Finally, alternative medicines and remedies are convenient to treat hiccups with uncertain effect. In conclusions, hiccup is likely to result from lesions involving the hiccup reflex arc. The lesion may need to be localized correctly for ablative treatment in patients with intractable hiccup. Apart from lesion ablation, drugs acting on reflex arc may be effective, while some other conventional measures may also be tried.

Corticosteroid rotation to alleviate dexamethasone-induced hiccup: a case series at a single institution

Dexamethasone, one of the key medications for the prevention of chemotherapy-induced nausea and vomiting (CINV), may cause hiccups as an adverse effect. In this case series, we present five patients who developed hiccups after receiving dexamethasone for CINV. We successfully switched dexamethasone to an equipotent dosage of either methylprednisolone or prednisolone, which resolved the hiccups while maintaining adequate control of CINV. This was achieved without changing the rest of the antiemetic regimen, chemotherapy doses, or the use of other medications such as baclofen, haloperidol, and metoclopramide for hiccups. Further studies on switching dexamethasone to alternative corticosteroids in patients developing hiccups after administration of dexamethasone are warranted.

Successful treatment of chronic hiccup with baclofen in cancer patients

Chronic hiccup is an infrequent but distressing symptom in patients with advanced cancer. A series of drugs (chlorpromazine, haloperidol, nifedipine, metoclopramide, baclofen) have been used to treat hiccup without definitive results. Some authors have suggested a possible role of baclofen in the treatment of chronic hiccup. We report three cases of chronic hiccup in patients with cancer successfully treated with baclofen.

Acupuncture treatment for persistent hiccups in patients with cancer

OBJECTIVE

The objective of this study was to investigate the effects of acupuncture treatment for persistent hiccups in cancer patients.

DESIGN

The study design was a retrospective case series.

SETTINGS/LOCATION

The study setting was the Clinical Research Center of the National Institutes of Health.

SUBJECTS

The subjects were 16 adult male patients ages 27-71 with cancer, with persistent hiccups.

INTERVENTIONS

There were one to three acupuncture sessions over a 1-7-day period.

OUTCOME MEASURES

Treatment efficacy was measured using a hiccup assessment instrument pre- and post-treatment. The effects of acupuncture on common symptoms reported by all patients were also evaluated.

RESULTS

Thirteen (13) patients experienced complete remission of persistent hiccups (p < 0.0001); 3 patients experienced decreased hiccups severity. Significant improvement was observed in discomfort (p < 0.0001), distress (p < 0.0001), and fatigue (p = 0.0078).

CONCLUSIONS

This case series demonstrates that acupuncture may be a clinically useful, safe, and low-cost therapy for persistent hiccups in patients with cancer.

Severe hiccups during chemotherapy: corticosteroids the likely culprit

Hiccups generally are self-limiting and of short duration. Those lasting more than 48 h or recurring at frequent intervals are termed persistent. There are numerous causes of hiccups, with medications implicated only rarely. While hiccups are usually benign, severe attacks may lead to exhaustion, eating difficulties, and affect quality of life. We report a case of severe hiccups in a patient receiving chemotherapy (oxaliplatin, 5-fluorouracil, leucovorin) for metastatic colorectal cancer. Hiccups began on the day following chemotherapy and continued constantly for over 30 h until relief was obtained by sucking the juice of a fresh lemonade. A similar pattern occurred in the next two chemotherapy cycles. Dexamethasone had been prescribed as prophylaxis against emesis and this was considered a possible cause. Withholding dexamethasone in the next cycle led to elimination of hiccups without having an impact on control of nausea and vomiting. A number of case reports have linked corticosteroids, particularly dexamethasone, to the occurrence of hiccups. Antineoplastic agents have occasionally been reported as causing hiccups; however, in most of these cases, corticosteroids, as part of the treatment protocol or as antiemetics, may have been a more likely cause. This case serves an as important reminder that adverse effects appearing during chemotherapy may not necessarily be due to antineoplastic agents. In the case of hiccups, oncology health professionals should review all medications and non drug-related factors before assigning causality. J Oncol Pharm Practice (2009) 15: 233—236.

Microvascular decompression for intractable singultus: technical case report

OBJECTIVE

Intractable singultus is a rare but significantly disruptive clinical phenomenon that often accompanies other diseases but can present in isolation due entirely to intracranial pathology. We report a case of intractable singultus that improved after microvascular decompression and present a comprehensive review of singultus by discussing its similarity to other cases of microvascular decompression, its history and etiology, and its evolutionary basis.

CLINICAL PRESENTATION

The patient exhibited intractable singultus for 15 years, resistant to multiple medical regimens.

INTERVENTION

Microvascular decompression to relieve pressure on the tenth cranial nerve and medulla oblongata resulted in near total resolution of the singultus.

CONCLUSION

Neurovascular compression should be considered a potentially reversible cause of intractable singultus, a significantly disabling clinical phenomenon.

Hiccup and neurosurgeons: a report of 4 rare dorsal medullary compressive pathologies and review of the literature

OBJECTIVE

The aim of this study was to present 4 rare cases of medullary compressive lesions presenting with IH, to discuss the indications for neurosurgical decompression in such cases, and to review the possible etiologies of IH briefly.

METHODS

The reported cases include (1) a 19-year-old adolescent boy and a 21-year-old man with Chiari I malformation and cervical syrinx compressing or tightening the cervico-medullary junction; (2) a 35-year-old man with ependymoma extending from the lower half of the fourth ventricle to C1/C2 junction and compressing this part of the medulla; and (3) a 16-year-old adolescent boy who was referred to the emergency department in severe distress because of IH, occurring as a result of a distal PICA aneurysm located on the floor of the lower triangle of the fourth ventricle.

RESULTS

Surgical decompression in all the cases was successful in withholding the hiccups.

CONCLUSION

The dorsal medullary area is not an unusual location for genesis of hiccup. When encountering a case of IH, appropriate CNS imaging studies should be included in the evaluation protocol.

Cisplatin-related hiccups: male predominance, induction by dexamethasone, and protection against nausea and vomiting

Dexamethasone is likely to play a role in the etiology of hiccups in patients receiving cisplatin-based regimens. Two hundred seventy-seven patients received three doses of ondansetron 8mg intravenously (IV) at 4hour intervals plus dexamethasone 20mg IV from the start of chemotherapy, followed by dexamethasone 5mg IV every 12hours, until chemotherapy was complete. Hiccups were observed in 114 (41.2%) patients, of whom 97.4% were men. Nausea and vomiting showed inverse correlations with hiccups (P < 0.0001 and P = 0.001, respectively). In 73 patients who experienced hiccups but lacked nausea/vomiting (H+N/V-), we discontinued dexamethasone in subsequent cycles. Sixty-six patients (90.4%) ceased hiccuping, but complete protection rates of nausea and vomiting decreased to 63% and 74%, respectively. For patients who experienced both hiccups and nausea/vomiting, the onset of nausea/vomiting usually was delayed to Day 3 or 4 and began after the cessation of hiccups. We conclude that cisplatin-related hiccups are predominant in males, dexamethasone-induced, and associated with protection against nausea/vomiting.