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Management Case No 7.Hiccup Management.

Hiccup_Management

Larynx এর opening কে বলা হয় Glottis, এই Glottis এর চার পাশে থাকে কিছু Cartilage, যাকে বলা হয় Epiglottis…

যদি কোনো কারণে Diaphragm এর involuntary contraction হতে থাকে, তাহলে তা Intercoastal muscle সমূহকে spasm করবে,

[[[এই রকম sudden, intermittent involuntary contraction of diaphragm + intercostal muscle এর কারণে কি হবে?

sudden inspiration হবে, যা incomplete + Glottis এর মধ্যে একটা প্রেশার পড়বে, Glottis বারবার বন্ধ হবে, খুলবে, এই Glottis close হবার সময় Larynx এর Muscle সমূহে আবার spasm হতে থাকে, একটা *Hic * উচ্চারণ এর মত sound হয়… যাকে Hiccup বলা হয়—–]]]

Hiccup এ ১০০% মানুষ ই জীবনের কোনো না কোনো সময় আক্রান্ত হয়— Body তে কোনো প্যাথলজি না থাকলে এইটা সর্বোচ্চ ৪৮ ঘন্টা থাকে– এর মধ্যে প্রতি মিনিটে ৪ থেকে ৬০ বার হতে পারে—

পেশেন্ট আসলে কি করবেন–

আগে থেকে GERD এর হিস্ট্রি থাকলে GERD এর চিকিৎসা দিবেন–

GERD এর হিস্ট্রি না থাকলে Vomiting /Diarrhoea history থাকলে একটা Serum urea And serum electrolyte, serum creatinine করে নিবেন-

Cause খুজে পেলে সেই হিসাবে চিকিৎসা

সব কিছু নরমাল থাকলে Rx হবে-

Spasm কমানোর জন্য Muscle relaxant Baclofen.

antiemetic : Domperidone

সাথে GERD symptoms থাকলে Antacid syrup দেওয়া যেতে পারে-

Dopamine receptor blocker : Chlorpromazin ভালো কাজ করে,

opsonil নামে পাওয়া যায়, তবে এইটা যেনো First line Rx না হয়-

এইটা Antipsychotic Medication..

এইটা Extra-pyramidal symptoms করতে পারে,৷ তবে ২-৩ দিন এর জন্য symptomatic Relief এ মেজর কোনো সাইড ইফেক্ট দেখায়না–

Acute severe Hiccup :

No electrolyte imbalance

Serum urea normal:

Rx:: Tab1- Beklo 10 mg (AS A Baclofen Centrally acting Skeletal Muscle Relaxants).

Indications of Tab- Beklo 10 mg (AS A Baclofen Centrally acting Skeletal Muscle Relaxants).

Beklo is indicated in-

  • spasticity resulting from multiple sclerosis
  • flexor spasms and concomitant pain, clonus and muscular rigidity
  • skeletal muscle spasm resulting from rheumatic disorders
  • spinal cord injuries and other spinal cord diseases
  • cerebrovascular accidents or neoplastic or degenerative brain disease

Pharmacology Tab- Beklo 10 mg (AS A Baclofen Centrally acting Skeletal Muscle Relaxants).

Baclofen inhibits both monosynaptic and polysynaptic reflexes at the spinal level by stimulating the GABAB receptors, which inhibits the release of glutamate and aspartate. It may also act at intraspinal sites producing CNS depression. Baclofen also exerts an antinociceptive effect.

Dosage & Administration

Adult & children over 10 years: 5 mg 3 times daily, preferably with or after food, gradually increased; max. 100 mg daily.

Children <10 years: Treatment is usually started with 2.5 mg (2.5 ml) given 4 times daily then raised according to requirement. Daily maintenance dose-

  • 12 month-2 years: 10-20 mg (10-20 ml)
  • 2 years-6 years: 20-30 mg (20-30 ml)
  • 6 years-10 years: 30-60 mg (30-60 ml)

Interaction Tab- Beklo 10 mg (AS A Baclofen Centrally acting Skeletal Muscle Relaxants).

  • Increased sedation may occur if Beklo is taken with agents acting on the central nervous system, alcohol or synthetic opiates. The risk of respiratory depression is also increased.
  • Combined treatment with Beklo and antihypertensives is likely to increase the fall in blood pressure; therefore the dosage of antihypertensive medication should be adjusted accordingly.
  • The concomitant administration of Beklo and tricyclic antidepressants may potentiate the pharmacological effects of Beklo resulting in pronounced muscular hypotonia.
  • In patients with Parkinsons disease receiving treatment with Beklo and levodopa and carbidopa, there have been several reports of mental confusion, hallucinations, headaches, nausea and agitation.
  • The concurrent use of MAO inhibitors and Beklo may result in increased CNS depressant effects. Caution is advised and the dosage of one or both agents should be adjusted accordingly.
  • Caution should be exercised when administering Beklo and magnesium sulphate or other neuromuscular blocking agents since a synergistic effect may theoretically occur.

Contraindications

Baclofen is contraindicated in patients with hypersensitivity to any component of this product.

Side Effects Tab- Beklo 10 mg (AS A Baclofen Centrally acting Skeletal Muscle Relaxants).

The most common adverse reactions associated with Beklo are transient drowsiness, daytime sedation, dizziness, weakness and fatigue.

  • Central Nervous System: Headache (<10%), insomnia (<10%), and rarely, euphoria, excitement, depression, confusion, hallucinations, paraesthesia, nightmares, muscle pain, tinnitus, slurred speech, co-ordination disorder, tremor, rigidity, dystonia, ataxia, blurred vision, nystagmus, strabismus, miosis, mydriasis, diplopia, dysarthria, epileptic seizures, respiratory depression.
  • Cardiovascular: Hypotension (<10%), rare instances of dyspnoea, palpitation, chest pain, syncope.
  • Gastrointestinal: Nausea (approximately 10%), constipation (<10%) and rarely, dry mouth, anorexia, taste disorder, abdominal pain, vomiting, diarrhoea and positive test for occult blood in stool.
  • Genitourinary: Urinary frequency (<10%) and rarely, enuresis, urinary retention, dysuria, impotence, inability to ejaculate, nocturia, haematuria.
  • Other: Instances of rash, pruritus, ankle oedema, excessive perspiration, weight gain, nasal congestion, visual disturbances, hepatic function disorders and paradoxical increase in spasticity. Muscular hypotonia of a degree sufficient to make walking or movement difficult may occur but is usually relieved by readjusting the dosage. For this purpose, the daytime dosage may be reduced and the evening dosage increased.

Pregnancy & Lactation

Pregnancy category B3. Safe use of Baclofen during pregnancy has not been established. Baclofen crosses the placental barrier. Baclofen should only be administered to pregnant women when in the judgement of the physician concludes that the potential benefits outweigh the possible hazards. Baclofen is excreted in breast milk however evidence to date suggests that the quantities are so small that no undesirable effects on the infant would be expected.

Precautions & Warnings Tab- Beklo 10 mg (AS A Baclofen Centrally acting Skeletal Muscle Relaxants).

  • Lower doses (approximately 5 mg per day) should be used for patients with impaired renal function or those undergoing chronic haemodialysis.
  • Patients suffering not only from spasticity but also from psychotic disorders, schizophrenia, depressive or manic disorders or confusional states should be treated cautiously and closely monitored as exacerbations of these disorders may occur.
  • In patients with epilepsy and muscle spasticity, Beklo may be used under appropriate supervision and provided that adequate anticonvulsive therapy is continued. Lowering of the convulsion threshold may occur and seizures have been reported after the cessation of Beklo therapy or with overdose.
  • Beklo should be used with caution in patients with or with a history of peptic ulcers, cerebrovascular diseases, or hepatic, renal or respiratory failure.
  • Careful monitoring of respiratory and cardiovascular function is essential especially in patients with cardiopulmonary disease and respiratory muscle weakness.
  • During treatment with Beklo, neurogenic disturbances affecting emptying of the bladder may improve. However in patients with preexisting sphincter hypertonia, acute retention of urine may occur. Beklo should be used with caution in these circumstances.
  • Beklo has not significantly benefited patients with stroke. These patients have also shown poor tolerance to the medicine.
  • Appropriate laboratory tests should be performed periodically in patients with hepatic diseases or diabetes mellitus to ensure that no medicine induced changes in these underlying diseases have occurred.

Overdose Effects

Gastric lavage is important in case of severe overdose.

Therapeutic Class Tab- Beklo 10 mg (AS A Baclofen Centrally acting Skeletal Muscle Relaxants).

Centrally acting Skeletal Muscle Relaxants

1+0+1 (3 days)

Tab2- Omidon 10 mg

1+0+1 (10 days)

Syrup3: Antacid

অসহনীয় Hiccup, Baclofen and Omdion এ রেস্পন্স না করলে- Chlorpromazin add করতে পারেন-

Tablet4:-Opsonil 100 mg .(As A Chlorpromazine Hydrochloride As a Anti-emetic drugs, Phenothiazine drugs, Phenothiazine related drugs).

Indications of Tablet:-Opsonil 100 mg .(As A Chlorpromazine Hydrochloride As a Anti-emetic drugs, Phenothiazine drugs, Phenothiazine related drugs).

Opsonil is indicated in the following conditions:

  • Schizophrenia and other psychoses (especially paranoid), mania and hypomania.
  • In anxiety psychomotor agitation excitement, violent or dangerously impulsive behaviour. Opsonil is used as an adjunct in the short-term management of these conditions.
  • Intractable hiccup.
  • Nausea and vomiting of terminal illness (where other medicines have failed or are not available).
  • Childhood schizophrenia and autism.

Pharmacology Tablet:-Opsonil 100 mg .(As A Chlorpromazine Hydrochloride As a Anti-emetic drugs, Phenothiazine drugs, Phenothiazine related drugs).

Chlorpromazine acts as an antagonist (blocking agent) on different postsysnaptic receptors -on dopaminergic-receptors (subtypes D1, D2, D3 and D4 – different antipsychotic properties on productive and unproductive symptoms), on serotonergic-receptors (5-HT1 and 5-HT2, with anxiolytic, antidepressive and antiaggressive properties as well as an attenuation of extrapypramidal side-effects, but also leading to weight gain, fall in blood pressure, sedation and ejaculation difficulties), on histaminergic-receptors (H1-receptors, sedation, antiemesis, vertigo, fall in blood pressure and weight gain), alpha1/alpha2-receptors (antisympathomimetic properties, lowering of blood pressure, reflex tachycardia, vertigo, sedation, hypersalivation and incontinence as well as sexual dysfunction, but may also attenuate pseudoparkinsonism – controversial) and finally on muscarinic (cholinergic) M1/M2-receptors (causing anticholinergic symptoms like dry mouth, blurred vision, obstipation, difficulty/inability to urinate, sinus tachycardia, ECG-changes and loss of memory, but the anticholinergic action may attenuate extrapyramidal side-effects). Additionally, Chlorpromazine is a weak presynaptic inhibitor of Dopamine reuptake, which may lead to (mild) antidepressive and antiparkinsonian effects. This action could also account for psychomotor agitation and amplification of psychosis (very rarely noted in clinical use).

Dosage & Administration Tablet:-Opsonil 100 mg .(As A Chlorpromazine Hydrochloride As a Anti-emetic drugs, Phenothiazine drugs, Phenothiazine related drugs).

Adults: In general medicine and psychiatry-

  • Oral route: average daily dose of 30 to 75 mg (mild cases) or 75 to 100 mg (more severe cases) in divided doses. It is occasionally necessary to give a higher dosage which, when increased gradually, can reach 900 mg or more per day in some psychiatric patients.
  • Once the optimum dosage has been reached, it is maintained as long as necessary for the control of symptoms during the critical phase of the illness. Eventually, however, it should be gradually reduced so that the patient can be maintained on the lowest effective dosage.

Adults: In surgery and anesthesia-

  • To potentiate hypnotics, analgesics and anesthetics and as an antiemetic.
  • Oral route: doses of 25 to 50 mg are administered 2 to 3 hours before anesthesia and every 4 to 6 hours after surgery.

Children:

  • Usual single dose: 1/4 mg per pound (1/2 mg/kg) by oral route. This dose can be repeated every 4 to 6 hours as necessary. The normal daily dose is 40 mg for a child of 5 years (40 pounds), 75 mg for children of 5 to 12 years (50 to 100 pounds) except in psychiatric patients where dosages can be progressively elevated above these levels.
  • In surgery and anesthesia, doses of 1/4 mg per pound, by the same method recommended for adults.

‘

Interaction

Interactions resulting in decreased chlorpromazine levels: Food, alcohol and benztropine can reduce the absorption of chlorpromazine. Antacids can slow the absorption of chlorpromazine. Lithium and chronic administration of barbiturates can lead to increased clearance of chlorpromazine.

Interactions resulting in increased chlorpromazine levels: Tricyclic antidepressants decrease the clearance of chlorpromazine and may lead to increased serum levels. Administration of chlorpromazine with CYP1A2 inhibitors, in particular strong (such as ciprofloxacin and fluvoxamine) or moderate (such as oral contraceptives and vemurafenib) inhibitors leads to an increase in chlorpromazine plasma concentrations. Therefore, patients may experience any chlorpromazine dose-dependent adverse drug reaction.

Contraindications

Severe CNS depression or comatose states due to alcohol, barbiturates, analgesics or other CNS depressants. In patients with blood dyscrasias, severe liver disease or a sensitivity to phenothiazines.

Side Effects Tablet:-Opsonil 100 mg .(As A Chlorpromazine Hydrochloride As a Anti-emetic drugs, Phenothiazine drugs, Phenothiazine related drugs).

Drowsiness frequently occurs at the beginning of treatment but gradually disappears or subsides with a downward adjustment of the dosage – also at the beginning of treatment, there are rare cases of orthostatic hypotension, particularly when high doses are used – dystonic and extrapyramidal reactions may appear during prolonged treatment with elevated dosages, but can be eliminated by lowering the doses or administering an antiparkinsonian agent.

Other side effects which are observed less frequently include: nasal congestion, blurred vision, xerostomy, sedation, nausea, constipation, changes in libido, gynecomastia, weight gain, skin and corneal pigmentation, photosensitivity, blood dyscrasias, leukopenia, eosinophilia and EEG changes.

Very rare cases of QT interval prolongation have been reported. There have been isolated reports of sudden death, with possible causes of cardiac origin, as well as cases of unexplained sudden death, in
patients receiving neuroleptic phenothiazines.

Cholestatic jaundice and liver injury, mainly of cholestatic or mixed type, are rarely reported in patients treated with Opsonil.

Systemic lupus erythematosis has been very rarely reported in patients treated with Opsonil. In some cases, positive anti-nuclear antibodies may be seen without evidence of clinical disease.

Priapism has been very rarely reported in patients treated with Opsonil.

Pregnancy & Lactation

Pregnancy category C. Studies in animals by oral route have shown reproductive toxicity (dose-related embryo fetotoxicity: increased resorptions and dead foetuses). Increased incidence of malformations was observed in mice but only at doses inducing maternal mortality. There is inadequate animal data regarding reproductive toxicity with chlorpromazine by parenteral route. In humans, the teratogenic risk of chlorpromazine has not been evaluated. Different prospective epidemiological studies conducted with other phenothiazines have yielded contradictory results regarding teratogenic risk. Chlorpromazine has been found to be excreted in breast milk in variable amounts, therefore it is not recommended for nursing mothers unless the expected benefits outweigh any potential risk.

Precautions & Warnings

Opsonil can potentiate the effects of other phenothiazines and CNS depressants. When treatment is initiated, the usual doses of barbiturates, analgesics, narcotics or antihistamines should be reduced by half. Patients should be warned against consuming alcoholic beverages while on Opsonil therapy.

Neuroleptic phenothiazines may potentiate QT interval prolongation. QT prolongation is exacerbated, in particular, in the presence of bradycardia, hypokalemia, and congenital or acquired (i.e., drug induced) QT prolongation.

Opsonil should be used cautiously in patients suffering from arteriosclerosis, cardiovascular disease or other conditions where it is necessary to avoid a sudden drop in blood pressure. If hypotension does occur and it is necessary to use a hypertensive agent, norepinephrine should be used, not epinephrine, as the latter agent can aggravate hypotension.

Because of its anticholinergic properties, Opsonil must be used with caution in patients with glaucoma or prostatic hypertrophy.

During protracted therapy and especially if high dosages are administered, it is recommended that blood counts and liver function tests be performed at regular intervals.

Drowsiness may occur at the beginning of treatment; patients should therefore be warned against operating motor vehicles or participating in activities requiring mental alertness until this effect has subsided.

Phenothiazines can provoke epileptic seizures by lowering the seizure threshold; therefore, during Opsonil therapy, the patient’s usual anticonvulsant medication should be continued at the same dosage.

Because of its antiemetic effect, Opsonil can obscure symptoms of intracranial hypertension or intestinal obstruction.

False positive or negative pregnancy tests have occurred in patients receiving phenothiazine therapy.

Use in Special Populations

Elderly: The elderly are relatively more susceptible to the adverse effects of chlorpromazine. The starting dose should be about half the usual adult dose and dosage increments should be gradual and reviewed regularly.

Therapeutic Class Tablet:-Opsonil 100 mg .(As A Chlorpromazine Hydrochloride As a Anti-emetic drugs, Phenothiazine drugs, Phenothiazine related drugs).

Anti-emetic drugs, Phenothiazine drugs, Phenothiazine related drugs

Chlorpromazin and Domperidone এক সাথে দিবেন না-

Chlorpromazin (inj: opsonil 50 mg I/M 8 hourly for 3 days)

তাহলে severe এর ক্ষেত্রে Rx হতে পারে–

Tab- beklo 10 mg

1+0+1 (3-5 days)

Tab- opsonil 50 / inj- Opsonil 50 mg I/M 8 hourly. (3-5 daysl

Tab- Rabe 20 mg

1+0+1 (15 days)

General Quaries:-

1.Largactil orally deya jabe na?

Tablet:-Opsonil 100 mg .(As A Chlorpromazine Hydrochloride As a Anti-emetic drugs, Phenothiazine drugs, Phenothiazine related drugs)

Answer is:-… Oral /IM dite paren

2:

Hiccup এর GP এ Common কারণ হলো Liver Abscess and Sub diaphragmatic Abscess . এর সাথে CKD এবং Electrolyte Balance.

Treatment of the cause will eradicate the symptoms.

3.

Chlorpromazine + domperidone keno aksathe deya jai na…

Answer is:-

Domperidone increases the risk of QT prolongatio, when given with Chlorpromazine.

Raiyyan Tahsan ❤️ Date:12-01-2025 Sunday Time:8-26-34 PM

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