Effects of Rikkunshito (traditional Japanese medicine) on enteral feeding and the plasma ghrelin level in critically ill patients: a pilot study

The efficacy and safety of prokinetics in critically ill adults receiving gastric feeding tubes: A systematic review and meta-analysis

Background

Intolerance to gastric feeding tubes is common among critically ill adults and may increase morbidity. Administration of prokinetics in the ICU is common. However, the efficacy and safety of prokinetics are unclear in critically ill adults with gastric feeding tubes. We conducted a systematic review to determine the efficacy and safety of prokinetics for improving gastric feeding tube tolerance in critically ill adults.

Methods

Randomized controlled trials (RCTs) were identified by systematically searching the Medline, Cochrane and Embase databases. Two independent reviewers extracted the relevant data and assessed the quality of the studies. We calculated pooled relative risks (RRs) for dichotomous outcomes and the mean differences (MDs) for continuous outcomes with the corresponding 95% confidence intervals (CIs). We assessed the risk of bias using the Cochrane risk-of-bias tool and used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology to rate the quality of the evidence.

Results

Fifteen RCTs met the inclusion criteria. A total of 10 RCTs involving 846 participants were eligible for the quantitative analysis. Most studies (10 of 13, 76.92%) showed that prokinetics had beneficial effects on feeding intolerance in critically ill adults. In critically ill adults receiving gastric feeding, prokinetic agents may reduce the ICU length of stay (MD -2.03, 95% CI -3.96, -0.10; P = 0.04; low certainty) and the hospital length of stay (MD -3.21, 95% CI -5.35, -1.06; P = 0.003; low certainty). However, prokinetics failed to improve the outcomes of reported adverse events and all-cause mortality.

Conclusion

As a class of drugs, prokinetics may improve tolerance to gastric feeding to some extent in critically ill adults. However, the certainty of the evidence suggesting that prokinetics reduce the ICU or hospital length of stay is low. Prokinetics did not significantly decrease the risks of reported adverse events or all-cause mortality among critically ill adults.

Effect of Rikkunshito, a Traditional Japanese Herbal Medicine, on Delayed Gastric Emptying and Oral Dietary Intake After Pancreaticoduodenectomy: A Prospective, Randomized, Single-Center, Open-Labeled Study

Introduction

Delayed gastric emptying (DGE) remains an important problem after pancreaticoduodenectomy (PD). There is a lack of effective treatments for early recovery of oral dietary intake. Rikkunshito (RKT), a Japanese herbal medicine, has been gaining attention as a facilitator of gastric emptying. We evaluated the effects of RKT on DGE after PD.

Methods

In this prospective, randomized, open-labeled study, patients were randomly allocated before PD in a 1:1 ratio to the RKT group or the control group that received no additional treatment. The RKT group received 2.5 g of RKT three times daily (7.5 g/day) from postoperative day (POD) 1 to POD 21. The primary endpoint was the incidence of DGE. Secondary endpoints were short-term postoperative outcomes including oral dietary intake volume and perioperative changes in levels of the hormones ghrelin and leptin. Patients were observed until hospital discharge.

Results

Twenty-six patients in each group (n = 52) completed the protocol treatment and were included in the analysis set. There were no statistically significant differences in basic characteristics and operative factors. The overall incidence of DGE was not statistically different between the RKT and control groups (30.8% vs 30.8%, p>0.9999). There were no statistically significant differences in the amount of postoperative oral dietary intake represented by total dietary intake (TDI) up to POD 14 and POD 21, complications, and length of hospital stay. No adverse events related to this study were observed. In the RKT group, total ghrelin and acyl-ghrelin were significantly upregulated and leptin was significantly downregulated earlier than in the control group.

Conclusion

RKT treatment from POD 1 to 21 did not reduce the incidence of DGE and had no clinically beneficial effect on short-term postoperative outcomes irrespective of changes in hormone levels.

Kampo Medicine for Various Aging-Related Symptoms: A Review of Geriatric Syndrome

With the continued growth of the aging population in Japan, geriatric syndrome (GS), which is associated with aging-related symptoms, has become a social problem. GS is caused by physiological and pathological aging and may manifest various symptoms. Physicians use multidisciplinary approaches to provide treatment for individual GS symptoms. Kampo medicine, a Japanese traditional medicine that uses multiple pharmacologically active substances, is useful for many syndromes, conditions, disorders, and diseases associated with GS. Evidence of the effectiveness of Kampo medicine for GS has accumulated in recent years. The effects of Kampo treatment for symptoms related to functional decline of the cardiovascular, respiratory, and digestive systems, cognitive impairment and related disorders, pain and other sensory issues, among others, support the use of Kampo medicine for the management of GS. The role of Kampo medicine for GS is summarized in this review.

Effect of hangebyakujutsutemmato on pregabalin‐induced dizziness in a rat model of neuropathic pain

Aim

This study investigated the efficacy of hangebyakujutsutemmato (HBT) in alleviating disturbances of equilibrium using a rat pregabalin model of neuropathic pain with dizziness. Pregabalin is effective for treating neuropathic pain, but some patients cannot tolerate continued treatment owing to dizziness resulting from pregabalin, especially shortly after beginning treatment. HBT is a Japanese kampo medicine that is used to treat dizziness.

Methods

Rats with chronic constriction injury of the sciatic nerve (Bennett and Xie model) underwent the beam balance test to evaluate their sense of equilibrium. The animals were divided into four groups, as follows: pregabalin (50 mg/kg) + HBT (1 g/kg; PH), n = 8; pregabalin (50 mg/kg; P), n = 8; HBT (1 g/kg; H), n = 8; and water (N), n = 8. Pregabalin and HBT treatments were initiated 9 days following injury.

Results

On postoperative day 10 (POD10), the day after starting drug treatment, there was a significant difference in the crossing time between PH and P (P < 0.01). The crossing time in group P recovered to a level similar to the other groups on POD16.

Conclusion

HBT alleviated the disturbance of equilibrium resulting from pregabalin in a rat model of neuropathic pain. This suggests that HBT may also alleviate dizziness and/or accelerate recovery from dizziness due to pregabalin treatment in humans.

The effect of standard and high dose of rikkunshito on achievement of enteral nutrition target in critically ill patients: a pilot randomized controlled trial

Aim

Rikkunshito is a traditional Japanese medicine used for delayed gastric emptying in intensive care units in Japan. This study aimed to investigate whether standard‐ or high‐dose rikkunshito can improve the achievement of enteral calorie target among critically ill adults.

Methods

This open‐label, single‐center, pilot randomized controlled trial was carried out from March 2018 until December 2018 and enrolled critically ill adult patients requiring enteral nutrition by gastric tube for at least 5 days. Patients were randomized into the control group, the standard‐dose rikkunshito group (2.5 g three times daily), and the high‐dose rikkunshito group (5 g three times daily). Intervention was given for 5 days. The primary outcome measure was the percentage of enteral calorie intake achieved in the target at the fifth day after randomization.

Results

The cohort comprised 26 patients; of these, 9, 8, and 9 were included in the control group, the standard‐dose group, and the high‐dose group, respectively. Twenty‐one patients (81%) were included in the primary analysis. The percentage of enteral calorie intake achieved in the target at the fifth day was 59% (interquartile range [IQR], 39–63%), 40% (IQR, 26–61%), and 62% (IQR, 17–83%) in the control, the standard‐dose, and the high‐dose groups, respectively (P = 0.42). The number of adverse events did not differ significantly between the groups (control group, 4 [44%]; standard‐dose group, 3 [38%]; and high‐dose group, 4 [44%], P = 1.00).

Conclusions

Standard‐ or high‐dose rikkunshito did not improve the achievement of enteral calorie target in critically ill adults.

Rikkunshito for upper gastrointestinal symptoms: A systematic review and meta-analysis

BACKGROUND

Upper gastrointestinal symptoms are major issues in various diseases such as postgastrectomy syndrome and functional dyspepsia. These symptoms cannot be fully controlled in such conditions and result in poorer quality of life. Rikkunshito has been traditionally used in Japan to relieve these symptoms. This systematic review assessed the efficacy and safety of rikkunshito for relieving upper gastrointestinal symptoms.

METHODS

A systematic literature search was conducted using Ovid MEDLINE, Scopus, the Cochrane Central Register of Controlled Trials, and ICHUSHI. Randomized controlled trials comparing rikkunshito to alternative drugs for the treatment of upper gastrointestinal symptoms were searched without language restriction. Two review authors independently assessed the literature and extracted data from identified studies. The risk of bias in each study was assessed.

RESULTS

Twenty-four studies with a combined total of 2175 participants were included in this review. Rikkunshito did not significantly relieve upper gastrointestinal symptoms when compared with other treatments via the Gastrointestinal Symptom Rating Scale (standardized mean difference, -0.07; 95% confidence interval [CI], -0.31 to 0.17; P =  0.59), while it significantly relieved the symptoms on a 5-point scale (mean difference, -0.38; 95% CI, -0.55 to -0.21; P <  0.001). No drug-related severe adverse events were reported. Most of the included studies had high or unclear overall risk of bias.

CONCLUSIONS

It remains still unclear whether rikkunshito is effective for the relief of upper gastrointestinal symptoms. Further high-quality studies are needed.

Effects of Rhubarb on Intestinal Dysmotility in Critically Ill Patients

Intestinal dysmotility is a major problem in critically ill patients. This report describes the successful treatment of intestinal dysmotility with rhubarb as a laxative in six critically ill patients on mechanical ventilation. Bowel movement and defecation occurred in all patients an average of 1.8 days after the administration of powdered rhubarb. In 4 patients who also had gastric reflux, the reflux volume via nasal tube was decreased an average of 3.5 days after the initiation of rhubarb treatment, and enteral nutrition was able to be started. Rhubarb may be useful for the treatment of incompetent gastric and intestinal motility in critically ill patients.

Extracts of Immature Orange (Aurantii fructus immaturus) and Citrus Unshiu Peel (Citri unshiu pericarpium) Induce P-Glycoprotein and Cytochrome P450 3A4 Expression via Upregulation of Pregnane X Receptor

P-glycoprotein (P-gp) and cytochrome P450 3A4 (CYP3A4) are expressed in the intestine and are associated with drug absorption and metabolism. Pregnane X receptor (PXR) is the key molecule that regulates the expression of P-gp and CYP3A4. Given that PXR activity is regulated by a variety of compounds, it is possible that unknown PXR activators exist among known medicines. Kampo is a Japanese traditional medicine composed of various natural compounds. In particular, immature orange [Aurantii fructus immaturus (IO)] and citrus unshiu peel [Citri unshiu pericarpium (CP)] are common ingredients of kampo. A previous study reported that kampo containing IO or CP decreased the blood concentration of concomitant drugs via upregulation of CYP3A4 although the mechanism was unclear. Some flavonoids are indicated to alter P-gp and CYP3A4 activity via changes in PXR activity. Because IO and CP include various flavonoids, we speculated that the activity of P-gp and CYP3A4 in the intestine may be altered via changes in PXR activity when IO or CP is administered. We tested this hypothesis by using LS180 intestinal epithelial cells. The ethanol extract of IO contained narirutin and naringin, and that of CP contained narirutin and hesperidin. Ethanol extracts of IO and CP induced P-gp, CYP3A4, and PXR expression. The increase of P-gp and CYP3A4 expression by the IO and CP ethanol extracts was inhibited by ketoconazole, an inhibitor of PXR activation. The ethanol extract of IO and CP decreased the intracellular concentration of digoxin, a P-gp substrate, and this decrease was inhibited by cyclosporine A, a P-gp inhibitor. In contrast, CP, but not IO, stimulated the metabolism of testosterone, a CYP3A4 substrate, and this was inhibited by a CYP3A4 inhibitor. These findings indicate that the ethanol extract of IO and CP increased P-gp and CYP3A4 expression via induction of PXR protein. Moreover, this induction decreased the intracellular substrate concentration.