DEXAMETHASONE-INDUCED HICCUPS IN A PATIENT WITH COVID-19 PNEUMONIA

Abstract

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Dexamethasone has been shown to reduce 28-day mortality in patients with severe COVID-19 pneumonia who required oxygen supplementation or invasive mechanical ventilation according to the RECOVERY trial. With the global COVID-19 pandemic, we are seeing increasing use of dexamethasone. This may lead to increased incidence of side effects as well. One of the side effects of dexamethasone therapy is hiccups which can range in presentation from mild and transient to persistent, causing distress and impaired quality of life. CASE PRESENTATION: A 59-year-old male with past medical history of type 2 diabetes mellitus and hypertension presented to the hospital with chief complaint of shortness of breath. Vitals were remarkable for acute hypoxic respiratory failure, improved with oxygen supplementation. Computerized tomography (CT) of the chest with contrast both showed bilateral airspace opacities. COVID-19 PCR was positive. Patient was diagnosed with COVID-19 pneumonia and started on remdesevir and dexamethasone. On day 3 of therapy, patient endorsed having hiccups without aggravating or relieving factors. These hiccups were suspected to be secondary to dexamethasone after initial evaluation. Gabapentin therapy was planned for relief, but patient s hiccups resolved after 24 hours. Patient completed the remaining dexamethasone therapy without incident. DISCUSSION: This brief case highlights the importance of recognizing dexamethasone induced hiccups as a clinical entity that may increase in incidence given increasing utility of dexamethasone in patients with severe COVID-19 pneumonia. Previous studies described this phenomenon in patients who were prescribed dexamethasone for chemotherapy induced nausea. They noticed that rotating dexamethasone with prednisolone in patients who developed hiccups significantly reduced the hiccups intensity. The hiccups were thought to be due to dexamethasone being more permeable to and crossing the blood brain barrier to stimulate the hiccups reflex arc in the midbrain. For patients with COVID-19 who meet criteria for dexamethasone, it may be prudent to continue with dexamethasone despite hiccups if quality of life is not significantly impaired due to lack of convincing evidence regarding efficacy of other steroids in COVID-19. Therapies such as gabapentin, metoclopramide and baclofen have been proposed for hiccups that are significantly affecting quality of life. Dexamethasone induced hiccups usually resolve upon discontinuing the drug. As such, most patients usually require reassurance or brief pharmacotherapy for hiccups. CONCLUSIONS: Dexamethasone may cause hiccups during the course of therapy for severe COVID-19 pneumonia. These hiccups are usual transient and resolve upon discontinuation of the drug. REFERENCE #1: Lee GW, Oh SY, Kang MH, Kang JH, Park SH, Hwang IG, Yi SY, Choi YJ, Ji JH, Lee HY, Bruera E. Treatment of dexamethasone-induced hiccup in chemotherapy patients by methylprednisolone rotation. Oncologist. 2013;18(11):1229-34. doi: 10.1634/theoncologist.2013-0224. Epub 2013 Oct 9. PMID: 24107973;PMCID: PMC3825309. DISCLOSURES: No relevant relationships by Muhammad Hasib Khalil, source=Web Response