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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 )


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