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Marijuana for intractable hiccups
Ian Gilson, Mary Busalacchi
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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