JOURNAL OF PALLIATIVE MEDICINE Volume 18, Number 7, 2015 ª Mary Ann Liebert, Inc. DOI: 10.1089/jpm.2015.0106
Hiccups during Chemotherapy: What Should We Do? Jung Hun Kang, MD1 and Eduardo Bruera, MD 2
Dear Editor: We read with great interest the case report by Silvia and Flavia.1 The authors described a male patient who suffered from recurrent hiccups during FOLFOX (5-fluorouracil, leucovorin, oxaliplatin) chemotherapy with antiemetic medications (ondasetron, dexamethasone). He developed severe hiccups starting the day after chemotherapy. The hiccups did not respond to multiple therapeutic agents, but they were relieved by a sip of vinegar. We would like to suggest a possible explanation for hiccups in this patient. Our team has observed that dexamethasone causes hiccups when used as part of chemotherapy regimens.2 The pattern of hiccup recurrence with chemotherapy cycles in this case suggests that hiccups was induced by medications during chemotherapy. Verdy et al. reported that up to 25% of patients developed hiccups after dexamethasone.3 Male gender also increases the risk of dexamethasone-induced hiccups.4 Since the main purpose of dexamethasone in chemotherapy is preventing emesis, it might be possible to change dexamethasone for another corticosteroid. Under this assumption, we found that hiccups during chemotherapy could be controlled without losing antiemetic potential by replacing dexamethasone with methylprednisolone.2,4 We also observed that the severity of hiccups was attenuated by readministration of dexamethasone.4 The authors wrote in the case presentation that ‘‘hiccups continued constantly for seven days with only a few hours of daily relief’’ in the first cycle and lessened by about eight hours in the second cycle. Based on our previous finding, it is possible that
1 2
hiccup tolerance contributed to mitigation of the symptom over time. In conclusion, preventing chemotherapy-related hiccups is better than controlling it. A very useful measure in hiccups during chemotherapy is to prevent further episodes by replacing dexamethasone with methylprednisolone. References
1. Gonella S, Gonella F: Use of vinegar to relieve persistent hiccups in an advanced cancer patient. J Palliat Med 2015; 18:467–470. 2. Kang JH, Hui D, Kim MJ, et al.: Corticosteroid rotation to alleviate dexamethasone-induced hiccup: A case series at a single institution. J Pain Symptom Manage 2012;43:625–630. 3. Vardy J, Chiew KS, Galica J, et al.: Side effects associated with the use of dexamethasone for prophylaxis of delayed emesis after moderately emetogenic chemotherapy. Br J Cancer 2006;94:1011–1015. 4. Lee GW, Oh SY, Kang MH, et al.: Treatment of dexamethasoneinduced hiccup in chemotherapy patients by methylprednisolone rotation. Oncologist 2013;18:1229–1234.
Address correspondence to: Jung Hun Kang, MD Gyeongsang University College of Medicine Department of Internal Medicine Chilam-ro 79 Jinju, Korea 660-702 E-mail: [email protected]
Department of Internal Medicine, College of Medicine, Gyeongsang University Hospital, Jinju, South Korea. Department of Palliative Care and Rehabilitation Medicine, University of Texas M.D. Anderson Cancer Center, Houston, Texas.
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Hiccups during Chemotherapy: What Should We Do? Jung Hun Kang, MD1 and Eduardo Bruera, MD 2
Dear Editor: We read with great interest the case report by Silvia and Flavia.1 The authors described a male patient who suffered from recurrent hiccups during FOLFOX (5-fluorouracil, leucovorin, oxaliplatin) chemotherapy with antiemetic medications (ondasetron, dexamethasone). He developed severe hiccups starting the day after chemotherapy. The hiccups did not respond to multiple therapeutic agents, but they were relieved by a sip of vinegar. We would like to suggest a possible explanation for hiccups in this patient. Our team has observed that dexamethasone causes hiccups when used as part of chemotherapy regimens.2 The pattern of hiccup recurrence with chemotherapy cycles in this case suggests that hiccups was induced by medications during chemotherapy. Verdy et al. reported that up to 25% of patients developed hiccups after dexamethasone.3 Male gender also increases the risk of dexamethasone-induced hiccups.4 Since the main purpose of dexamethasone in chemotherapy is preventing emesis, it might be possible to change dexamethasone for another corticosteroid. Under this assumption, we found that hiccups during chemotherapy could be controlled without losing antiemetic potential by replacing dexamethasone with methylprednisolone.2,4 We also observed that the severity of hiccups was attenuated by readministration of dexamethasone.4 The authors wrote in the case presentation that ‘‘hiccups continued constantly for seven days with only a few hours of daily relief’’ in the first cycle and lessened by about eight hours in the second cycle. Based on our previous finding, it is possible that
1 2
hiccup tolerance contributed to mitigation of the symptom over time. In conclusion, preventing chemotherapy-related hiccups is better than controlling it. A very useful measure in hiccups during chemotherapy is to prevent further episodes by replacing dexamethasone with methylprednisolone. References
1. Gonella S, Gonella F: Use of vinegar to relieve persistent hiccups in an advanced cancer patient. J Palliat Med 2015; 18:467–470. 2. Kang JH, Hui D, Kim MJ, et al.: Corticosteroid rotation to alleviate dexamethasone-induced hiccup: A case series at a single institution. J Pain Symptom Manage 2012;43:625–630. 3. Vardy J, Chiew KS, Galica J, et al.: Side effects associated with the use of dexamethasone for prophylaxis of delayed emesis after moderately emetogenic chemotherapy. Br J Cancer 2006;94:1011–1015. 4. Lee GW, Oh SY, Kang MH, et al.: Treatment of dexamethasoneinduced hiccup in chemotherapy patients by methylprednisolone rotation. Oncologist 2013;18:1229–1234.
Address correspondence to: Jung Hun Kang, MD Gyeongsang University College of Medicine Department of Internal Medicine Chilam-ro 79 Jinju, Korea 660-702 E-mail: [email protected]
Department of Internal Medicine, College of Medicine, Gyeongsang University Hospital, Jinju, South Korea. Department of Palliative Care and Rehabilitation Medicine, University of Texas M.D. Anderson Cancer Center, Houston, Texas.
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