Source: The Lancet - Volume 351, Number 9098
Authors: Ian Gilson, Mary Busalacchi
Pubdate: Sat, 24 Jan 1998
Marijuana For Intractable Hiccups
A patient with AIDS and a history of oesophageal candidosis underwent minor
ambulatory surgery. He was on indinavir, and he received perioperative intravenous
midazolam and dexamethasone. The following morning he developed persistent hiccups.
Chlorpromazine controlled the hiccups only during sleep. Oral nifedipine, valproate,
lansoprazole, and intravenous lidocaine had no effect. Glabellar acupuncture on day six
and nine terminated the hiccups for less than an hour. Removal of a hair from the
tympanic membrane on day 8 and irrigation of marcaine into the external auditory canal
on day nine gave only brief relief. On day eight the patient, who had not smoked
marijuana before, smoked marijuana, and his hiccups stopped. They recurred on day
nine and on day ten the patient again smoked marijuana; hiccups stopped immediately
and did not recur. On day 14 he was found to have fluconazole-resistant oesophageal
candidosis on oesophagoscopy, and was treated with oral itraconazole solution and oral
amphotericin B.
Intractable hiccups has been reported as an uncommon complication of AIDS; in the
largest series, most cases were attributed to oesophageal candidosis and other oesophageal
diseases.1 This patient did have oesophageal candidosis, but it was longstanding and his
hiccups stopped before a change in treatment, so this is unlikely to be the cause of his
hiccups. Midazolam2 and dexamethsone3 are the drugs most commonly associated with
iatrogenic hiccups. The patient received both shortly before the onset of hiccups, and
indinavir may have prolonged the effect of midazolam by inhibiting its metabolism.
Although midazolam is contraindicated in patients on protease inhibitors, it and other
proscribed drugs may be inadvertently administered if the potential for drug-drug
interactions is not considered.
Anecdotal reports support the use of marijuana in AIDS-related nausea and anorexia, and
dronabinol is approved for treatment of AIDS wasting. Because intractable hiccups is an
uncommon condition, it is unlikely that the use of marijuana will ever be tested in a
controlled clinical trial, and blinding would be difficult. Despite federal policy which
forbids the use of marijuana therapeutically,4 this report should be considered for hiccups
refractory to other measures.
1 Albrecht H, Stellbrink HJ. Hiccups in people with AIDS. J Acquir Immun Defic
Syndr 1994; 7: 735
2 de Mendonca MJT. Midazolam-induced hiccoughs. Br Dent J 1984; 157: 49
3 Vasquez JJ. Persistent hiccup as a side effect of dexamethasone treatment. Hum Exp
Toxicol 1993; 13: 32.
4 Kassirer JP. Federal foolishness and marijuana. N Engl J Med 1997; 336: 366
Aurora Medical Group, Milwaukee, WI 53212, USA ( I Gilson )
