Benefits of ginger in the control of chemotherapy-induced nausea and vomiting

OBJECTIVES

To identify and discuss scientific evidence of the effects of ginger use on the management of chemotherapy-induced nausea and vomiting.

METHODS

This is an integrative reviewperformed by Ganong's reference.

RESULTS

We included 24 studies, highlighting three thematic categories, namely 1) antiemetic action of ginger - nausea (13 articles; of these, nine significant) and emesis (10 studies; of these, six significant); 2) action in the control of nausea (11 articles; of these, six significant) and vomiting (8 articles; of these, three significant) in the acute phase; 3) action in the control of nausea (6 articles; of these, three significant) and vomiting (6 articles; of these, three significant) in the delayed phase. There were divergences of the methods used.

FINAL CONSIDERATIONS

This complementary therapy has low cost and easy access, but no statistical confirmation of its effectiveness in the management of nausea and vomiting in cancer patients was found.

Ginger and its pungent constituents non-competitively inhibit activation of human recombinant and native 5-HT3 receptors of enteric neurons

BACKGROUND

Beneficial effects of ginger in the treatment of gastrointestinal (GI) problems and chemotherapy-induced nausea and vomiting are well accepted. In rodents, the action of ginger seems to be mediated by the inhibition of 5-HT3 receptors, which are established targets to combat emesis and irritable bowel syndrome.

METHODS

Heterologously expressed human 5-HT3 A or 5-HT3 AB receptors were characterized by means of Ca(2+) influx studies using HEK293 cells. Complementing Ca(2+) measurements in Fluo-4-AM-stained whole-mount preparations of the human submucous plexus were carried out. Furthermore, [3H]GR65630 binding assays were performed to reveal the mode of action of ginger and its pungent compounds.

KEY RESULTS

We show for the first time that ginger extracts and its pungent arylalkane constituents concentration-dependently inhibit activation of human 5-HT3 receptors. Ginger extracts inhibited both receptors with increasing content of pungent compounds, confirming that these are part of ginger's active principle. Inhibition potencies of the arylalkanes 6-gingerol and 6-shogaol on both receptors were in the low micromolar range. A lipophilic ginger extract and 6-gingerol had no influence on 5-HT potency, but reduced the 5-HT maximum effect, indicating non-competitive inhibition. The non-competitive action was confirmed by [(3) H]GR65630 binding, showing that the ginger extract did not displace the radioligand from 5-HT3 A and 5-HT3 AB receptors. The potential relevance of the inhibitory action of ginger on native 5-HT3 receptors in the gut was confirmed in whole-mount preparations of the human submucous plexus. While a general neurotoxic effect of 6-gingerol was ruled out, it inhibited the 2-methyl-5-HT-mediated activation of 5-HT3 receptors residing on enteric neurons.

CONCLUSIONS & INFERENCES

Our findings may encourage the use of ginger extracts to alleviate nausea in cancer patients receiving chemotherapy and to treat functional GI disorders.

Effect of ginger on acute and delayed chemotherapy-induced nausea and vomiting: a pilot, randomized, open-label clinical trial

BACKGROUND

Nausea and vomiting are among the most prevalent and disturbing side effects of chemotherapy. Therefore, there is a need for additional antiemetic agents that could effectively reduce chemotherapy-induced nausea and vomiting (CINV), whether alone or in combination with current standard therapies. Since clinical data on the effectiveness of ginger in patients with advanced breast cancer is lacking, the present study aimed to evaluate the effects of ginger against both acute and delayed forms of CINV in a population with advanced breast cancer as the main malignancy.

METHODS

In this pilot, randomized, open-label clinical trial, 100 women (mean age = 51.83 ± 9.18 years) with advanced breast cancer who were initially assigned to standard chemotherapy protocol with docetaxel, epirubicin, and cyclophosphamide (the TEC regimen) were randomized to receive ginger (1.5 g/d in 3 divided doses every 8 hours) plus standard antiemetic regimen (granisetron plus dexamethasone; the ginger group) or standard antiemetic regimen alone (control group). The duration of treatment with ginger was specified to 4 days from the initiation of chemotherapy. Prevalence, score, and severity of nausea, vomiting, and retching were assessed using a simplified form of Rhodes index in the first 6 hours, between 6 to 24 hours, and days 2, 3, and 4 postchemotherapy.

RESULTS

A significantly lower prevalence of nausea was observed in the ginger group during 6 to 24 hours postchemotherapy. Despite this effect, no other significant additional benefit from ginger (1.5 g/d) was observed against prevalence or severity of nausea, vomiting, and retching in any of the assessed periods.

CONCLUSION

Addition of ginger (1.5 g/d) to standard antiemetic therapy (granisetron plus dexamethasone) in patients with advanced breast cancer effectively reduces the prevalence of nausea 6 to 24 hours postchemotherapy. However, there is no other additional advantage for ginger in reducing prevalence or severity of acute or delayed CINV.

Antiemetic Use in Oncology: Updated Guideline Recommendations from ASCO

In 2011, ASCO updated its guideline for the use of antiemetics in oncology, informed by a systematic review of the medical literature. This is an abbreviated version of that guideline, which is available in full at www.asco.org/guidelines/antiemetics. Key changes from the prior update in 2006 include the following: Combined anthracycline and cyclophosphamide regimens were reclassified as highly emetic. Patients who receive this combination or any highly emetic agents should receive a 5-HT3 receptor antagonist, dexamethasone, and an NK1 receptor antagonist. A large trial validated the equivalency of fosaprepitant, a single-day intravenous formulation, with aprepitant; either therapy is appropriate. Preferential use of palonosetron is recommended for moderate emetic risk regimens, combined with dexamethasone. For low-risk agents, patients can be offered dexamethasone before the first dose of chemotherapy. Patients undergoing high emetic risk radiation therapy should receive a 5-HT3 receptor antagonist before each fraction and for 24 hours following treatment and may receive a 5-day course of dexamethasone during fractions 1 to 5. Continued symptom monitoring throughout therapy is recommended. Clinicians often underestimate the incidence of nausea, which is not as well controlled as vomiting. Detailed information about the development of the guideline as well as practice tools are available at www.asco.org/guidelines/antiemetics.

Anti-emetic effect of ginger powder versus placebo as an add-on therapy in children and young adults receiving high emetogenic chemotherapy

PURPOSE

Chemotherapy-induced nausea and vomiting (CINV) are major adverse effects of chemotherapy. Ginger has been used in postoperative and pregnancy-induced nausea and vomiting. Data on its utility in reducing CINV in children and young adults are lacking.

PATIENTS AND METHODS

Sixty chemotherapy cycles of cisplatin/doxorubicin in bone sarcoma patients were randomized to ginger root powder capsules or placebo capsules as an additional antiemetic to ondensetron and dexamethasone in a double-blind design. Acute CINV was defined as nausea and vomiting occurring within 24 hr of start of chemotherapy (days 1-4) and delayed CINV as that occurring after 24 hr of completion of chemotherapy (days 5-10). CINV was evaluated as per Edmonton's Symptom Assessment Scale and National Cancer Institute criteria respectively.

RESULTS

Acute moderate to severe nausea was observed in 28/30 (93.3%) cycles in control group as compared to 15/27 (55.6%) cycles in experimental group (P = 0.003). Acute moderate to severe vomiting was significantly more in the control group compared to the experimental group [23/30 (76.7%) vs. 9/27 (33.33%) respectively (P= 0.002)]. Delayed moderate to severe nausea was observed in 22/30 (73.3%) cycles in the control group as compared to 7/27 (25.9%) in the experimental group (P < 0.001). Delayed moderate to severe vomiting was significantly more in the control group compared to the experimental group [14/30 (46.67%) vs. 4/27 (14.81%) (P = 0.022)].

CONCLUSION

Ginger root powder was effective in reducing severity of acute and delayed CINV as additional therapy to ondensetron and dexamethasone in patients receiving high emetogenic chemotherapy (ClinicalTrials.gov identifier: NCT00940368).

Evaluation of new antiemetic agents and definition of antineoplastic agent emetogenicity--state of the art

Antiemetic drug development can follow the same logical path as antineoplastic drug development from appropriate preclinical models through Phase I, Phase II, and Phase III testing. However, due to the marked success of antiemetic therapy over the last 25 years, placebo antiemetic treatment against highly or moderately emetogenic chemotherapy is not acceptable. Promising antiemetic agents therefore rapidly reach Phase III testing, where they are substituted into or added to effective and accepted regimens. One challenge of antiemetic drug development is determining whether substitution is indeed acceptable or whether prior regimens must be maintained intact as a basis for further antiemetic drug development. An additional challenge is the classification of emetogenic level of new antineoplastic agents. Accurate reporting of emetogenicity of such antineoplastic agents in the absence of preventive antiemetic treatment may not be available. However, at the 2009 Multinational Association of Supportive Care in Cancer (MASCC)/European Society of Medical Oncology (ESMO) Consensus Conference, an expert panel used best available data to establish rankings of emetogenicity. Oral chemotherapeutic agents are ranked separately from intravenous agents, recognizing intrinsic differences in emetogenicity as well as differing schedules of administration. Since oral chemotherapeutic agents are often administered in extended regimens, the distinction between acute and delayed emesis is less clear, and cumulative emesis must be considered. As control of vomiting has improved, attention has shifted to control of nausea, a related but distinct and equally important problem. Additional efforts will be necessary to understand mechanisms of nausea and to identify optimal remedies.

5-HT(3) receptors: role in disease and target of drugs

Serotonin type 3 (5-HT(3)) receptors are pentameric ion channels belonging to the superfamily of Cys-loop receptors. Receptor activation either leads to fast excitatory responses or modulation of neurotransmitter release depending on their neuronal localisation. 5-HT(3) receptors are known to be expressed in the central nervous system in regions involved in the vomiting reflex, processing of pain, the reward system, cognition and anxiety control. In the periphery they are present on a variety of neurons and immune cells. 5-HT(3) receptors are known to be involved in emesis, pain disorders, drug addiction, psychiatric and GI disorders. Progress in molecular genetics gives direction to personalised medical strategies for treating complex diseases such as psychiatric and functional GI disorders and unravelling individual drug responses in pharmacogenetic approaches. Here we discuss the molecular basis of 5-HT(3) receptor diversity at the DNA and protein level, of which our knowledge has greatly extended in the last decade. We also evaluate their role in health and disease and describe specific case-control studies addressing the involvement of polymorphisms of 5-HT3 subunit genes in complex disorders and responses to drugs. Furthermore, we focus on the actual state of the pharmacological knowledge concerning not only classical 5-HT(3) antagonists--the setrons--but also compounds of various substance classes targeting 5-HT(3) receptors such as anaesthetics, opioids, cannabinoids, steroids, antidepressants and antipsychotics as well as natural compounds derived from plants. This shall point to alternative treatment options modulating the 5-HT(3) receptor system and open new possibilities for drug development in the future.

Response to "Radiation therapeutic gain and Asian botanicals," by Stephen Sagar

Numerous botanical agents, many of which are used in whole medical system practices (i.e. traditional Chinese medicine, Ayurvedic medicine, etc.), have been shown to exhibit radiomodifying effects on tumors and normal tissues in-vitro and in-vivo studies. Some of these agents can enhance the therapeutic gain of radiation therapy by either acting as a radiosensitizer to tumor cells and/or as a radioprotector to normal cells. Botanical agents are comprised of multiple phytochemical compounds that may work individually or synergistically to not only improve radiation therapy outcomes, but may also exhibit a variety of anti-cancer effects as well. It will be important to evaluate these botanicals for efficacy, tumor specificity, and safety profiles before they can be recommended during radiation therapy.