Elsevier

Phytomedicine

Volume 50, 15 November 2018, Pages 8-18
Phytomedicine

Ginger (Zingiber officinale): An alternative for the prevention of postoperative nausea and vomiting. A meta-analysis

https://doi.org/10.1016/j.phymed.2018.09.007Get rights and content

Abstract

Background

Postoperative nausea and vomiting (PONV) is a distressing outcome related to surgeries. Traditionally, ginger has been used in the treatment of nausea and vomiting for thousands of years. Recently, several randomized, placebo-controlled clinical trials (RCTs) have been conducted to evaluate the efficacy of ginger in PONV.

Purpose

To systematically evaluate the efficacy of ginger on postoperative nausea and vomiting (PONV) compared to placebo, based on RCTs.

Study design

The meta-analysis was reported following the PRISMA guidelines using the PICO format, and it was registered with the PROSPERO register.

Methods

PubMed, Embase, the Cochrane Central Register of Controlled Trials and Web of Science were searched for relevant studies. Human, placebo-controlled clinical studies of patients undergoing any types of surgery, receiving pharmacological doses of ginger per os were included. Only clinical trials with explicit description of the ginger preparation used were analysed. No language or publication year restrictions was applied.

Results

Ten randomized trials including a total of 918 patients were pooled for the statistical analysis. The present meta-analysis supports that ginger has a significant effect on the severity of PONV based on visual analogue scale (VAS) results: in a fixed effects model the pooled standardized mean difference (SMD) was –0.247 (favouring ginger; [LL]: –0.455, [UL]: –0.040, p-value: 0.019). Moreover, our results suggest that ginger reduces the incidence of postoperative nausea and vomiting, as well antiemetic drug demand; however, these effects are not statistically significant compared to placebo, which may be explained by underdosing.

Conclusions

According to our thorough meta-analysis ginger is safe and well tolerated, and decreases the severity of PONV, and may lower the incidence of postoperative nausea and vomiting, which in turn may reduce antiemetic drug demand, suggesting that ginger may be a useful alternative to antiemetic medications to alleviate PONV.

Introduction

Postoperative nausea and vomiting (PONV) is one of the most common complications in patients undergoing surgeries. In the postoperative setting patients may find PONV more distressing than postoperative pain (ASPAN'S evidence-based clinical practice guideline for the prevention and/or management of PONV/PDNV, 2006). PONV can lead to several secondary complications such as aspiration pneumonia, wound disruption, gastric herniation, dehydration and fatigue; therefore, it can elongate the time to recovery and increase care costs (Cao et al., 2017). The incidence of PONV and the intensity of symptoms may vary depending on several factors (Horn et al., 2014), including patient characteristics (e.g. gender, age, previous history of PONV or motion sickness) and surgical factors (e.g. type of surgery, length of anaesthesia, use of postoperative opioids) (Gan et al., 2014).

PONV is triggered by several receptor systems, thus preventing and treating PONV is a complex task. Dopamin (D2) antagonists (e.g. prochlorperazine, metoclopramide), serotonin 5-HT3 antagonists (e.g. ondansetron, granisetron), anticholinergics (scopolamine), antihistamines (H1 antagonists, e.g. dimenhydrinate) and neurokinin-1 (NK1) receptor antagonists (aprepitant, rolapitant) are recommended to alleviate PONV symptoms (Kovac, 2013). The use of these drugs is often limited by their side effects (e.g. in case of antihistamines, 5-HT3 antagonists) or availability (NK-1 receptor antagonists) (Hu et al., 2015, Toyoda et al., 2013, Fero et al., 2011). As the effectiveness of an antiemetic drug may be affected by the patient's characteristics, there is no gold standard for the treatment of PONV. Moreover, a modern antiemetic drug with negligible side-effects such as NK-1 receptor antagonists may not be available or affordable for all patients.

Ginger, an easily accessible plant in many Asian countries, has been traditionally used in the treatment of gastrointestinal disorders since ancient times (Sheikhi et al., 2015). Nowadays, it is still considered as an alternative therapy for nausea and vomiting (Sharifi-Rad et al., 2017). Ginger and its bioactive secondary metabolites, especially gingerols and shogaols interact with the 5-HT3 signalling pathway (Semwal et al., 2015). Moreover, ginger is reported to show anticholinergic and antihistaminergic activities in vitro, which may further contribute to its antiemetic effect (Abdel-Aziz et al., 2006, Pertz et al., 2011).

According to the European Medicines Agency's HMPC monograph, the use of ginger medicines containing 1–2 g of ginger per dose is based on their ‘well-established use’ for the treatment of nausea and vomiting in motion sickness (European Union herbal monograph on Zingiber officinale Roscoe, rhizoma EMA/HMPC/296,580/2012, 2012). Ginger is considered to be generally safe, but it should not be recommended for pregnant women because of its in vitro mutagenic effects (Srinivasan, 2017, Nagabhushan et al., 1987, Nakamura and Yamamoto, 1983). Upon consuming ginger medications, mild to moderate gastrointestinal side effects and sleepiness are reported to occur as the most common adverse effects (Assessment report on Zingiber officinale Roscoe, rhizoma EMA/HMPC/577856/2010). No serious adverse events have not been reported; therefore, the relative safety of ginger products could be a major benefit in therapy (Sharifi-Rad et al., 2017).

Recently, several RCTs have been conducted to evaluate the effectiveness of ginger in postoperative nausea and vomiting. The last systematic review on this topic was published more than twelve years ago (Chaiyakunapruk et al., 2006). Therefore, the aim of the present meta-analysis was to synthesize the published evidence, and evaluate the antiemetic efficacy of ginger in the postoperative setting.

Section snippets

Methods

The following PICO (patients, intervention, comparison, outcome) format was applied: P: postoperative patients; I: pharmacological doses of ginger given per os; C: placebo; and O: postoperative nausea and/or vomiting. The meta-analysis was performed using the preferred reporting items for systematic review and meta-analysis protocols (PRISMA-Protocol). The meta-analysis protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 21th April 2017

Literature search and study selection

Using the search terms ginger and nausea for the literature search of EMBASE, PubMed, the Cochrane Central Register of Controlled Trials and Web of Science databases, and removing duplicate results, the search yielded a total of 835 potentially relevant reports. One additional report (Janngam, 2003) was identified through screening the reference lists of the previous meta-analysis of this topic (Chaiyakunapruk et al., 2006). The RCTs to be included in the meta-analysis were selected according

Discussion

Ginger has been used to ameliorate gastrointestinal disorders (e.g. nausea, vomiting, diarrhoea, etc.) since ancient times (Sheikhi et al., 2015). Nowadays, ginger is used as a complementary herbal medicine for the treatment of postoperative nausea and vomiting (Sharifi-Rad et al., 2017). The present meta-analysis was designed to synthesize the available evidence for this use. Ten RCTs were identified in the literature, which included nearly 1000 postoperative patients, and led to mixed

Conclusions

Although ginger is safe and is generally better tolerated than synthetic medications for PONV, the scientific evidence supporting its use as a herbal medicine for the treatment of PONV is still limited. Our meta-analysis supports that ginger decreases the severity of PONV, and suggests that at higher doses (≥1000 mg) it may also reduce the incidence of postoperative nausea and vomiting, and thus the demand for a rescue antiemetic agent. According to literature data, higher doses of ginger

Acknowledgements

The authors thank Dora Bokor, PharmD, for proof-reading the manuscript.

Conflicts of interest

The authors declare no conflicts of interest.

Funding

This study was supported by an Economic Development and Innovation Operative Programme Grant (GINOP 2.3.2-15-2016-00048 to P.H.) from the National Research, Development and Innovation Office, the János Bolyai Research Scholarship from the Hungarian Academy of Sciences (to D.C.), and a research grant (115796) from the National Research, Development and Innovation Office (to D.C.). TL was supported by the European Union and the State of Hungary, co-financed by the European Social Fund within the

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