Many patients undergoing chemotherapy experience nausea and vomiting (Gralla 1999; Hesketh 1998). The symptoms can be severe, impairing a patient's quality of life (Osoba 1997), causing emotional distress (Love 1989), and aggravating cancer-related symptoms such as cachexia, lethargy and weakness (Griffin 1996; Roscoe 2000).
Postoperative nausea and vomiting (PONV) are common complaints after general, regional, or local anaesthesia (Watcha 1992). These symptoms can occur in up to 80% of people given an anaesthetic (Sadhasivam 1999).
Nausea and vomiting are commonly experienced by women in early pregnancy; the prevalence rates are 50-80% for nausea, and 50% for vomiting and retching (Miller 2002; Woolhouse 2006). The symptoms are most common in the first trimester, between 6 and 12 weeks, but can continue to 20 weeks and last longer than this in up to 20% of women (Jewell 2003; Miller 2002). If vomiting is intractable, it can be associated with weight loss, dehydration and electrolyte imbalances, and may lead to hospitalisation (Miller 2002). The symptoms are thought to be associated with rising levels of human chorionic gonadotrophin (hCG) or oestrogens (Goodwin 2002). Women experiencing nausea and vomiting during pregnancy can suffer considerable physical and psychological effects (Attard 2002; Chou 2003; Chou 2008). The symptoms can affect daily activities and relationships, and result in lost productivity and increased healthcare costs (Attard 2002; Piwko 2007).
Drug treatment for nausea and vomiting includes 5-HT3 receptor antagonists, antimuscarinics, antihistamines, dopamine antagonists, corticosteroids and vitamins (i.e. B6 and B12). The teratogenic effects of drugs (such as thalidomide) used in the past to control these symptoms have led to caution about prescribing medications in the first trimester of pregnancy.
Attard CL et al. The burden of illness of severe nausea and vomiting of pregnancy in the United States. American Journal of Obstetrics and Gynecology 2002; 186: S220-S227.
Chou FH et al. Psychosocial factors related to nausea, vomiting, and fatigue in early pregnancy. Journal of Nursing Scholarship 2003; 35: 119-25.
Chou FH et al. Relationships between nausea and vomiting, perceived stress, social support, pregnancy planning, and psychosocial adaptation in a sample of mothers: a questionnaire survey. International Journal of Nursing Studies 2008; 45: 1185-91.
Goodwin TM. Nausea and vomiting of pregnancy: an obstetric syndrome. American Journal of Obstetrics and Gynecology 2002; 186: S184-S189.
Gralla R et al. Recommendations for the use of antiemetics: Evidence-based, clinical practice guidelines. Journal of Clinical Oncology 1999; 17: 2971-94.
Griffin A et al. On the receiving end: V Patient perceptions of the side effects of chemotherapy in 1993. Annals of Oncology 1996; 7: 189-95.
Hesketh P et al. Methodology of antiemetic trials: response assessment, evaluation of new agents and definition of chemotherapy emotogenecity. Supportive Care Cancer 1998; 6: 221-7.
Jewell D. Nausea and vomiting in early pregnancy. American Family Physician 2003; 68: 143-4.
Love R et al. Side effects and emotional distress during cancer chemotherapy. Cancer 1989; 63: 604-12.
Miller F. Nausea and vomiting in pregnancy: the problem of perception--is it really a disease? American Journal of Obstetrics and Gynecology 2002; 186: S182-S183.
Osoba D et al. Effect of postchemotherapy nausea and vomiting on health-related quality of life. The Quality of Life and Symptom Control Committees of the National Cancer Institute of Canada Clinical Trials Group. Supportive Care Cancer 1997; 5: 307-13
Piwko C et al. The weekly cost of nausea and vomiting of pregnancy for women calling the Toronto Motherisk Program. Current Medical Research and Opinion 2007; 23: 833-40.
Roscoe J et al. Nausea and vomiting remain a significant clinical problem: trends over time in controlling chemotherapy-induced nausea and vomiting in 1413 patients treated in community clinical practices. Journal of Pain and Symptom Management 2000; 20: 113-21.
Sadhasivam S et al. The safety and efficacy of prophylactic ondansetron in patients undergoing modified radical mastectomy. Anesthesia and Analgesia 1999; 89: 1340-5.
Watcha MF, White PF. Postoperative nausea and vomiting: its etiology, treatment and prevention. Anesthesiology 1992; 77: 162-84.
Woolhouse M. Complementary medicine for pregnancy complications. Australian Family Physician 2007; 35: 695.
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How acupuncture can help
The best evidence for acupuncture's effectiveness is with postoperative nausea and vomiting (PONV) (Ezzo 2006a). The latest systematic review, based on 40 trials and nearly 5,000 patients, found acupuncture to be significantly better than sham treatment and at least as good as anti-emetic drugs, with minimal side-effects (Lee 2009). Trials published since this review gathered its data have also been consistently positive: acupressure at P6 (Soltani 2010), acupoint injection of droperidol at P6 (Zhu 2010), 24-hour acupoint stimulation (Frey 2009), acupuncture at several points (Ayoglu 2009), acupuncture at P6 (Puyang 2009, Frey 2009) and ear acupuncture (Sahmaddini 2008). There is one less consistently favourable review but that looked specifically at caesarean delivery under neuraxial anaesthesia (6 trials only): (Allen 2008).
For chemotherapy-induced nausea and vomiting, there is also substantial evidence supporting acupuncture and associated procedures, although it is not as consistent as that for PONV. The latest systematic review (Ezzo 2006b) is now several years old. It found that electro- (but not manual) acupuncture reduced the incidence of acute vomiting and self-administered acupressure appears to have a protective effect for acute nausea and can readily be taught to patients. Subsequent individual trials of acupuncture or electroacupuncture (Yang 2009; You 2009; Sima 2009; Gottschling 2008) have all reported significant benefits, while those for acupressure applied using a wristband have been mixed (Jones 2008; Molassiotis 2007; Shin 2006).
For nausea and vomiting in pregnancy, the results have been less convincing, with a mix of positive and equivocal results according to Ezzo et al's (2006a) systematic review and in subsequent trials (Aghadam 2010; Shin 2007; Heazell 2006). A review covering various treatments, including acupuncture, ginger, vitamin B and medications, concluded that there is a lack of high-quality evidence to support advice on any of them (Matthews 2010).
Acupuncture, electroacupuncture or acupressure have been used successfully as treatments for nausea and vomiting arising in various other circumstances, for example opioid-induced (Zheng 2008), radiotherapy-induced (Roscoe 2009; Bridge 2003), and post-myocardial infarction.(Dent 2003).
It is characteristic of virtually all the Western trials of acupuncture for nausea and vomiting that they have used just the one point, P6. While this point is certainly strongly indicated for these symptoms, and appears to have a marked specific effect, it is by no means the only candidate; in traditional practice a mixture of different points would usually be employed, related to individual patient characteristics.
See Table overleaf for further details of the cited studies.
In general, acupuncture is believed to stimulate the nervous system and cause the release of neurochemical messenger molecules (Han 2004; Zhou 2008; Lee 2009). The resulting biochemical changes influence the body's homeostatic mechanisms, thus promoting physical and emotional well-being (Pomeranz, 1987; Zhao 2008; Samuels 2008; Cheng 2009).. Stimulation of certain acupuncture points has been shown to affect areas of the brain that are known to reduce sensitivity to pain and stress, as well as promoting relaxation (Hui 2010).
Acupuncture may help to alleviate nausea and vomiting by:
- regulating gastric myo-electrical activity (Streitberger 2006)
- modulating the actions of the vagal nerve and autonomic nervous system (Huang2005)
- reducing vasopressin-induced nausea and vomiting and suppressing retrograde peristaltic contractions (Tatewaki 2005)
- regulating vestibular activities in the cerebellum (Streitberger 2006)