Thread by @iamnephrologist

🔥Uremic Hiccups

👉Could be intractable in CKD
⚡Nephrologist's nightmare‼
👉Vagal/ Phrenic N stimulation

❓Which of the following is not a usual cause of persistent hiccups in CKD🚫
@RenalFellowNtwk @askrenal @NephJC

🔢Usual causes of Hiccups in CKD
🔺️Uremia itself
🔺️Hypokalemia/Hypocalcemia/Hyperglycemia
🔺️Drugs- Steroids/BZD/Opioids/Antidopaminergics
🔺️Addictions-Alcohol/Smoking
🔺️Psychogenic/Anxiety
🔺️GERD
🔺️Infections- TB/Pneumonia/CNS infection

💠Simple age old ways could be effective (Treat Uremia first‼)
👉Usually involve glottic stimulation/ ⬆️pCO2 (Hypocarbia stimulates hiccups‼)

🔺️Holding breath
🔺️Drinking gulps of water
🔺️Eating tbsf peanut butter❗
🔺️Chewing lemon
🔺️Inhaling pepper
🔺️Breath holding

💠Uremic hiccups:
📛Pharmacologic treatment

1️⃣Chlorpromazine
👉Effective⚡
👉Centrally acting (dopamine antagonism)
👉Serious potential side effects
❗Hypotension
❗Urinary retention
❗Delirium

👉No longer recommended as first-line management

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💠Uremic hiccups:
📛Pharmacologic treatment

2️⃣Prokinetic agents/PPI/Defoaming agents
👉First line treatment in CKD
👉Less toxic
👉No dose adjustment/ drug-drug interaction
👉Metoclopramide also central dopamine antagonistic
👉Simethicone most common deforming agent

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💠Uremic hiccups:
📛Pharmacologic treatment

3️⃣Anticonvulsants
👉Effective but sedative
👉Valproate- Enzyme inhibitor/ Narrow therapeutic window
👉Gabapentin- Half dose in advanced CKD

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💠Uremic hiccups:
📛Pharmacologic treatment

4️⃣Baclofen 🚫
👉Contraindicated in CKD
⚠️Baclofen Encephalopathy

👉Drug choice now-a-days in non-CKD patients

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💠Uremic hiccups:
📛Pharmacologic treatment

5️⃣SSRI- Sertraline
🔴Effective via two mechanisms
👉Via peripheral serotonin receptors in GIT: ⬇️abnormal esophageal, gastric, or diaphragmatic mobility
👉Via central action on hiccup reflex arc

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💠Uremic hiccups:
📛Pharmacologic treatment

6️⃣Lidocaine: (Nebulization) Avoid aspiration‼
7️⃣Nifedipine- Avoid Hypotension‼
8️⃣Midazolam- Avoid sedation‼
9️⃣Methylphenidate- risk of abuse ( Drug for ADHD)

⚡Hiccup Reflex Arc (Steger M et al; Bailey 1943)

@askrenal @RenalFellowNtwk

🌸Hiccups: Interesting Hypothesis
💡Proof needed

doi: 10.1002/bies.201100194
#NephroNotes #FOAMed #MedTwitter #MedEd