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Effect of ginger on chemotherapy-induced nausea and/or vomiting in cancer patients.

INTRODUCTION

Ginger (zingiber officinale) is a perennial herbaceous plant of Southeast Asian origin. The plant grows mostly in Africa, China, Nigeria, Jamaica, Australia and North America. The root of the flowering plant is most commonly used. Its chemical structure contains such compounds as oleoresin, geranial, neral, b-fellandren, sineol, borneol, bisabolen, zingiberen, gingeroles, sogaoles, diterpenes, lypids, protein, starch and vitamins. (1,2) The plant is reported to have anti-inflammatory, antimicrobial, anticarcinogenic, antidiabetic, antilypidemic and antiemetic effects. Roman, Greek, Ottoman and Chinese historical records reveal that ginger was widely used for many years for these clinical features. Ginger, which is now registered in the pharmacopoeias of Austria, China, Egypt, Germany, England, Japan and Switzerland, is recommended for intestinal colitis and flatulence problems in the Ayurvedic pharmacopoeia. The root of ginger, which is registered at the German Federal Institute Commission E and which has an economic significance, is suggested for treatment of digestion problems and car-sickness. It is recorded in the United States pharmocopeia and the National Formulary as having been used as a carminative, an aromatic and a stimulant, and in King's American Dispensatory as beneficial for weight loss and cold hands and feet. Recently, non-chemical products have become popular for alternative cancer treatment, and there have been efforts to improve these alternative treatments. Among the recommended products, ginger is one of the encapsulated drug forms. It is a complementary food and is included in the safe herbal products list of the FDA. (2,3,4,5,6)

Several studies of ginger have suggested that the plant has many beneficial effects and no unfavourable effects have yet been reported. Ueda et al. (7) demonstrated anti-inflammatory effects of ginger. Therkleson et al. (8) found that ginger decreased pain and increased joint motility in patients with osteoarthritis. In another study, ginger was given to nasogastric tube-fed or mechanically-ventilated patients. The group receiving ginger had a lower incidence of mortality and pneumonia and a more effective gastric emptying than those not receiving. (9) Lianga et al. (10) reported improved upper gastrointestinal symptoms with the administration of ginger. The authors investigated the effects of ginger on gastric emptying, antral motility, proximal gastric dimensions, and postprandial symptoms and suggested that ginger may be symptomatically more beneficial in specific patient groups than placebo by altering the gastric half-emptying time and the frequency of contractions in the antrum. Tuntiwechapiful et al. (11) found that ginger had favourable effects on lung cancer cells and suggested a beneficial role for it in the treatment of lung cancer.

There are several completed and ongoing studies of the above-mentioned effects of ginger. Among these, ginger's antiemetic effect has been extensively studied. It is reported that this effect does not occur through the central nervous system, but rather is related to a peripheral pathway with aromatic, absorbent or carminative effects. (1) Researchers have also reported that 940mg of ginger root duff was more effective than dimenhydrinate and other antiemetic drugs in a study of 1489 subjects with sea-sickness.1 A meta-analysis by Ernst and Pittler (12) revealed that ginger may have positive effects on chemotherapy- or pregnancy-induced, or postoperative, nausea and/or vomiting. Ebrahimi et al. (13) reported the use of ginger in the complementary treatment of hyperemesis gravidarum. A fixed 1g of ginger was found to be more effective for reducing postoperative nausea and/ or vomiting than placebo in five randomized studies with a total of 363 patients, and the only side effect experienced was abdominal discomfort. (14)

While several studies demonstrated a positive effect of ginger on pregnancy-induced and postoperative nausea and/or vomiting, there is a limited number of studies that examine the effects of ginger on chemotherapy-induced nausea and/or vomiting. Molassiotis et al. (15) investigated pharmacological and non-pharmacological treatment modalities for nausea and/or vomiting in patients receiving chemotherapeutic drugs. They reported that 38.3% of clinicians had recommended ginger to such patients in order to avoid the well-known side effects of antiemetic drugs. Several studies have suggested that ginger is effective in the prevention of chemotherapy-induced nausea and/or vomiting during treatment of several cancer types, including osteosarcoma and gynecological cancers. (16,17,18,19) To our knowledge, there are no studies on the use of ginger for haematological cancer patients receiving chemotherapeutic agents. The present study was carried out to assess the effectiveness of ginger on patients receiving treatment for a haematological cancer in Turkey.

METHOD

The study was carried out on cancer patients receiving chemotherapeutic agents in the haematology clinic of a training hospital between March 01, 2011 and July 29, 2011. Thirty out of 45 patients agreeing to participate in the study formed the control group and the remaining 15 formed the intervention group. Informed consent was obtained from both the intervention and control group. A questionnaire for sociodemographic features was administered to patients. Treatment of patients in the intervention group was begun after they had attended outpatient haematology clinic. Two tablets (2x 400 mg) of ginger were administered to patients in the intervention group in both the morning and the evening throughout the course of treatment. All patients in the intervention and control groups also continued using a sodium bicarbonate mouth care solution in line with hospital protocol. Presence of nausea and/or vomiting was recorded by a nurse twice daily during chemotherapy and was recorded on the nausea and/or vomiting follow up form. For the control group all the questionnaires were administered, the antiemetic treatment of 3mg of setron IV was started according to the chemotherapy protocol, and the chemotherapy regimen was continued without administering ginger.

Criteria for inclusion were as follows:

* Patients were aged 18 years or older

* They had no communication deficits

* They had no oral or gastrointestinal abnormalities

* They were not experiencing malnutrition or other illnesses that might induce nausea and/or vomiting

No changes were made to patients' nutritional schedules and there were no additional interventions for nausea and/or vomiting. All patients participated in an educational program about nausea and/or vomiting before the administration of chemotherapy and ginger.

DATA SHEETS

Identification Form for Descriptive Characteristics: This form was prepared by the researchers and consisted of 31 questions for identifying patients' sociodemographic characteristics and several characteristics of nausea and/or vomiting. (1,2,12,13,15)

Nausea and/or Vomiting Follow-Up Form: This form was prepared by the researchers to identify the presence of nausea and/or vomiting, and was completed daily both in the morning and in the evening.

DATA ANALYSIS

Data analysis was performed by SPSS (Statistical Packages for the Social Sciences) 15.0 and the homogeneity test and x-square tests were used for the analyses.

ETHICAL APPROVAL AND PERMISSION

Approval from the ethics committee, informed consent from participants and permission from the hospital management were obtained.

RESULTS

Eighty percent of the patients in the intervention group were male and 20% female; 66.7% were aged 46 to 80 years; 86.7% had graduated from primary or middle school; and 46.7% were unemployed. Sixty percent of the control patients were male and 40% female; 56.7% were aged 46 to 80 years; 76.7% had graduated from primary or middle school; and 56.7% were unemployed. In the intervention group 66.7% of patients had a diagnosis of leukemia and 53.3% were on at least their second course of treatment. In the control group 63.3% of patients had a diagnosis of leukemia and 53.3% were on their first course of treatment. Forty percent of patients in the intervention group were smokers and 60% brushed their teeth. On the other hand, 20% of the control patients were smokers and 80% brushed their teeth. Statistical analysis revealed no differences between the characteristics of the intervention and control groups (p>0.05).

The presence of nausea and/or vomiting was examined in the patient groups receiving ginger or an antiemetic drug, and no vomiting or nausea was found to have occurred in those receiving ginger. The rate of nausea and/or vomiting was 76.7% in the group using only antiemetic drugs. A significant difference was found between the group receiving ginger and the group receiving antiemetic drugs, suggesting that ginger is effective for nausea and/or vomiting (p<0.05) (Table 2).

Of the patients receiving antiemetic drugs, 83.3% were female and 72.2% were male; 92.3% of patients were aged 20 to 45 years; and 64.7% of those aged 46 to 80 years experienced vomiting and/or nausea. 84.2% of those patients with a diagnosis of leukemia and 63.3% of those with a diagnosis of lymphoma experienced vomiting and/or nausea. The incidence of nausea was similar in the groups receiving the first treatment course, smoking or brushing their teeth, and in the other groups. Statistical analysis revealed no significant differences between the groups (p>0.05) (Table 3). No statistical analysis was performed for the comparison of sociodemographic characteristics, as no patients in the intervention group experienced nausea and/or vomiting.

DISCUSSION

Results of the present study suggest that ginger is more effective than an antiemetic drug (3 mg setron) for the prevention of nausea and/or vomiting in patients receiving chemotherapeutic agents. However, as a significant percentage of the patients in the control group (53.3%) was receiving at least a second course of treatment course when compared to the intervention group (46.7%), nausea and/or vomiting might have been triggered visually or olfactorily because of unfavourable experiences they had previously had.

In a similar study, Pillai et al. (19) administered a combination of 40 mg/[m.sup.2]/day cisplatin and 25 mg/[m.sup.2]/day doxorubicin to pediatric and young osteosarcoma patients aged 8 to 21 years for three days. Starch powder was given to the control group, and a ginger capsule (consisting of 167 mg of ginger powder to patients weighing 20-40 kg and 400mg to those between 40 and 60 kg) to the intervention group, twice a day. Ginger root powder was found to decrease the severity of acute and late chemotherapy-induced nausea and/or vomiting at a similar rate to both ondansetron and dexametazone.

Zick et al. (20) assigned 162 patients of similar sociodemographic characteristics to three groups to receive low-dose ginger, high-dose ginger or a placebo. The aim of the study was to compare the effect of high (2gr) and low (1gr) doses of ginger on the prevalence and severity of nausea and/ or vomiting. Interestingly, the authors found that the two different doses of ginger did not have different effects on acute and late nausea--vomiting.

Sontakke et al. (21) studied patients diagnosed histopathologically with malignancies. Ondansetron, metoclopramid and ginger were given to separate groups. This study found that full control over nausea was achieved by 86% of the group using ondansetron, by 62% of the group using ginger and by 58% of the group using metoclopramide. Ondansetron was shown to be significantly more effective for full control over nausea than metoclopramid and ginger, but no difference was found between the antiemetic effects of ginger and metoclopramid.

In a study of 28 cancer patients by Levine et al. (22) patients received chemotherapeutic drugs with a normal to high risk of emetic effect in their first course of treatment. Following the first chemotherapy course patients were divided into three groups. The first group received a diet containing moderate amounts of protein and ginger; the second group received a diet high in protein and ginger; and the third group received a normal diet. The authors reported significantly less nausea following the first course of chemotherapy in patients receiving a high protein and ginger diet than in patients in the other two groups.

Manusirivithaya et al. (23) investigated the effects of ginger on 48 patients with a gynaecological cancer who were receiving chemotherapy. In this study an antiemetic was given on the first day of treatment with cisplatine, which strongly induces emesis, and then patients were divided into two groups. Group A received 1g/day of ginger capsule orally for five days following the first chemotherapy course and group B received a placebo on the first day of the chemotherapy and metoclopramide orally for the following four days. Both regimens were effective in controlling acute and late nausea and/or vomiting in patients receiving two chemotherapy courses. Discomfort, as a side effect, occurred more frequently in patients receiving metoclopropamide than in patients receiving ginger.

CONCLUSION

Nausea and/or vomiting are common problems for patients receiving chemotherapy treatment and are difficult to control. Individuals receiving chemotherapy experience serious problems with eating due to the unfavourable effects of both their illness and nausea and vomiting, which impair their quality of life. Ingestion of ginger for preventing chemotherapy--induced nausea and/or vomiting may not only represent a cost-saving over more expensive pharmaceutical preparations, but also may help to prevent the side effects of antiemetic drugs and their possible interactions with other drugs. Guidance given to patients receiving chemotherapy treatments by health practitioners about the effects of ginger on reducing chemotherapy-induced nausea and/or vomiting may have a positive effect on the treatment and care of the patients.

DISCLOSURE STATEMENT

No sponsorships or competing interests have been disclosed for this article

REFERENCES

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Guler Balci Alparslan, MD, PhD, Ass. Prof., Osmangazi University; Ayse Ozkarman, MD, Lecturer, School of Health, Meelik Campus, Eskiehisr; Nuran Eskin, BN, Hospital of Osmangazi University; Songul Yilmaz, BN, Hospital of Osmangazi University; Meltem Akay, MD, PhD, Assc. Prof, Hospital of Osmangazi University; Ayfer Acikgoz, MD, PhD, Lecturer, School of Health, Meselik Campus, Eskisehir; Ozlem Orsal, MD, PhD, Ass. Prof., School of Health, Meselik Campus, Eskisehir
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Author:Alparslan, Guler Balci; Ozkarman, Ayse; Eskin, Nuran; Yilmaz, Songul; Akay, Meltem; Acikgoz, Ayfer;
Publication:Journal of the Australian Traditional-Medicine Society
Article Type:Report
Geographic Code:8AUST
Date:Mar 1, 2012
Words:2924
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