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)