Vertigo-reducing effect of ginger root. A controlled clinical study

Drug-Drug Interactions in Vestibular Diseases, Clinical Problems, and Medico-Legal Implications

Peripheral vestibular disease can be treated with several approaches (e.g., maneuvers, surgery, or medical approach). Comorbidity is common in elderly patients, so polytherapy is used, but it can generate the development of drug-drug interactions (DDIs) that play a role in both adverse drug reactions and reduced adherence. For this reason, they need a complex kind of approach, considering all their individual characteristics. Physicians must be able to prescribe and deprescribe drugs based on a solid knowledge of pharmacokinetics, pharmacodynamics, and clinical indications. Moreover, full information is required to reach a real therapeutic alliance, to improve the safety of care and reduce possible malpractice claims related to drug-drug interactions. In this review, using PubMed, Embase, and Cochrane library, we searched articles published until 30 August 2021, and described both pharmacokinetic and pharmacodynamic DDIs in patients with vestibular disorders, focusing the interest on their clinical implications and on risk management strategies.

Nutraceuticals for Peripheral Vestibular Pathology: Properties, Usefulness, Future Perspectives and Medico-Legal Aspects

Vestibular disorders may generate complex signs and symptoms, which may alter patients' balance and the quality of life. Dizziness and vertigo can strongly affect daily activities and relations. Despite the presence of conventional drugs, maneuvers, and surgery, another interesting therapeutic opportunity is offered by nutraceuticals. These molecules are often used in the treatment of dizziness and vertigo, but the rationale of their application is not always solidly demonstrated by the scientific evidence. Several substances have shown a variable level of efficacy/usefulness in this field, but there is lack of important evidence for most of them. From a medico-legal point of view, specific information must be provided to the patient regarding the efficacy and possibilities that the use of these preparations can allow. Administering the right nutraceutical to the proper patient is a fundamental clinical skill. Integrating conventional drug treatment with nutraceutical administration seems to be easy, but it may be difficult considering the (in part unexplored) pharmacodynamics and pharmacokinetics of nutraceuticals. The aim of the scientific community should be to elevate nutraceuticals to the same law and technical dignity of conventional drugs.

Clinical Evaluation of the Use of Ginger Extract in the Preventive Management of Motion Sickness

Background

Motion sickness can be triggered in a variety of situations and is characterized primarily by nausea and vomiting. Ginger is widely used in treating conditions including chemotherapy-associated gastrointestinal symptoms, morning sickness, postoperative nausea, and motion sickness.

Objectives

The primary study objective was to evaluate Zingiber officinale extract in the treatment of motion sickness. Secondary objectives were to evaluate treatment effect on Motion Sickness Assessment Questionnaire (MSAQ) score and subscores before and after treatment, and to evaluate treatment tolerability.

Methods

Open-label, single-arm study assessing motion sickness outcomes with and without pre-travel oral treatment with Zingiber officinale 160 mg extract (containing 8 mg gingerols). All patients answered the MSAQ on 4 separate occasions following a trip of at least 15 minutes in duration: Trip 1 (pretreatment) and Trips 2, 3, and 4 (after oral treatment with study medication). The primary end point was percentage of patients presenting improvement ≥20 score points on the MSAQ during Trip 2, Trip 3, and Trip 4 in comparison to pretreatment score (Trip 1). Secondary end points included percentage of patients presenting improvement in MSAQ subscores during Trips 2, 3, and 4; percentage of patients presenting treatment-related adverse events; and pre- and posttreatment physician assessment scores.

Results

One hundred eighty-four patients were included and 174 completed treatment. A reduction of ≥20 points in total MSAQ score points occurred in 26.52%, 29.89%, and 29.31% of patients from Trips 2, 3, and 4, respectively. There was no significant difference at Trips 2, 3, and 4 in number of patients presenting improvement ≥20 score points (P = 0.9579). There was a significant reduction in total MSAQ scores from Trips 2, 3, and 4 (P < 0.0001) compared with Trip 1. Total MSAQ scores did not vary at each trip taken under treatment (P = 0.28). There were significant (P < .001) improvements in all domain subscores from Trips 2, 3, and 4 in relation to scores from Trip 1. There was a significant improvement in physician assessment scores at Visit 2 (P < .0001). Adverse events were reported among 31 patients, mainly affecting the gastrointestinal system. Twenty-four patients (13.04%) reported 39 adverse events considered related to treatment. No significant change in physical exam was noted at Visit 2 in relation to Visit 1.

Conclusions

These open label, historically controlled study results suggest the need for randomized, blinded, placebo and active substance controlled clinical trials. (Curr Ther Res Clin Exp. 2020; 81:XXX–XXX)

Ginger: Panacea or Consumer’s Hype?

Ginger in its many forms, from juices of the fresh rhizome, to ginger powder and ginger essential oil, is growing in popularity for claimed universal health benefits. Nevertheless, and contrarily to the common notion of the public, ginger is not devoid of side effects, especially interactions with other drugs, and many of the claimed benefits remain to be substantiated. This work presents a comprehensive revision of the current state of the art on ginger pharmacokinetics and bioavailability, interaction with active pharmaceutical ingredients, raising awareness of the risks of uncontrolled ginger consumption. A second section of the work described the verified actions of various extracts of ginger, or of their main active ingredients, gingerols, based mainly on data obtained from controlled clinical trials. Finally, the last section is devoted to innovative technological solutions to improve the bioavailability of gingerols and ginger extracts that are expected to ultimately lead to the development of more consumer-compliant products.

Ginger-Mechanism of action in chemotherapy-induced nausea and vomiting: A review

Despite advances in antiemetic therapy, chemotherapy-induced nausea and vomiting (CINV) still poses a significant burden to patients undergoing chemotherapy. Nausea, in particular, is still highly prevalent in this population. Ginger has been traditionally used as a folk remedy for gastrointestinal complaints and has been suggested as a viable adjuvant treatment for nausea and vomiting in the cancer context. Substantial research has revealed ginger to possess properties that could exert multiple beneficial effects on chemotherapy patients who experience nausea and vomiting. Bioactive compounds within the rhizome of ginger, particularly the gingerol and shogaol class of compounds, interact with several pathways that are directly implicated in CINV in addition to pathways that could play secondary roles by exacerbating symptoms. These properties include 5-HT3, substance P, and acetylcholine receptor antagonism; antiinflammatory properties; and modulation of cellular redox signaling, vasopressin release, gastrointestinal motility, and gastric emptying rate. This review outlines these proposed mechanisms by discussing the results of clinical, in vitro, and animal studies both within the chemotherapy context and in other relevant fields. The evidence presented in this review indicates that ginger possesses multiple properties that could be beneficial in reducing CINV.

Comparison between the efficacy of ginger and sumatriptan in the ablative treatment of the common migraine

Frequency and torment caused by migraines direct patients toward a variety of remedies. Few studies to date have proposed ginger derivates for migraine relief. This study aims to evaluate the efficacy of ginger in the ablation of common migraine attack in comparison to sumatriptan therapy. In this double-blinded randomized clinical trial, 100 patients who had acute migraine without aura were randomly allocated to receive either ginger powder or sumatriptan. Time of headache onset, its severity, time interval from headache beginning to taking drug and patient self-estimation about response for five subsequent migraine attacks were recorded by patients. Patients(,) satisfaction from treatment efficacy and their willingness to continue it was also evaluated after 1 month following intervention. Two hours after using either drug, mean headaches severity decreased significantly. Efficacy of ginger powder and sumatriptan was similar. Clinical adverse effects of ginger powder were less than sumatriptan. Patients' satisfaction and willingness to continue did not differ. The effectiveness of ginger powder in the treatment of common migraine attacks is statistically comparable to sumatriptan. Ginger also poses a better side effect profile than sumatriptan.

Zingiberis rhizoma: a comprehensive review on the ginger effect and efficacy profiles

Zingiberis rhizoma is used as a broadspectrum antiemetic. We, therefore, conducted a comprehensive review of the literature to summarize the pharmacological and clinical effects of this popular plant material. Although clinical and experimental studies suggest that ginger has some antiemetic properties, clinical evidence beyond doubt is only available for pregnancy-related nausea and vomiting. Meta-analyses could not demonstrate the postoperative antiemetic effectiveness, and effect in motion sickness or nausea/vomiting of other ethiology. It also remains to be confirmed that proprietary ginger preparations are clinically useful to alleviate osteoarthritic or other pain, although there is no doubt that ginger constituents interfere with the inflammatory cascade and the vanilloid nociceptor. Ginger exerts in vitro antioxidative, antitumorigenic and immunomodulatory effects and is an effective antimicrobial and antiviral agent. Animal studies demonstrate effects on the gastrointestinal tract, the cardiovascular system, on experimental pain and fever, antioxidative, antilipidemic and antitumor effects, as well as central and other effects. The most relevant human pharmacological studies require a confirmatory study to exclude interaction of ginger preparations with platelet aggregation. Pharmacokinetic data are only available for [6]-gingerol and zingiberene. Preclinical safety data do not rule out potential toxicity, which should be monitored especially following ginger consumption over longer periods.

Effectiveness and safety of ginger in the treatment of pregnancy-induced nausea and vomiting

OBJECTIVE

Conventional antiemetics are burdened with the potential of teratogenic effects during the critical embryogenic period of pregnancy. Thus, a safe and effective medication would be a welcome addition to the therapeutic repertoire. This systematic review was aimed at assessing the evidence for or against the efficacy and safety of ginger (Zingiber officinale) therapy for nausea and vomiting during pregnancy.

DATA SOURCES

Systematic literature searches were conducted in 3 computerized databases (MEDLINE, EMBASE, and Cochrane Library), and the reference lists of all papers located were checked for further relevant publications.

METHODS OF STUDY SELECTION

For the evaluation of efficacy, only double-blind, randomized controlled trials (RCTs) were included. All retrieved clinical data, including uncontrolled trials, case reports, observational studies, and RCTs, were included in the review of safety.

TABULATION, INTEGRATION, AND RESULTS

Six double-blind RCTs with a total of 675 participants and a prospective observational cohort study (n = 187) met all inclusion criteria. The methodological quality of 4 of 5 RCTs was high. Four of the 6 RCTs (n = 246) showed superiority of ginger over placebo; the other 2 RCTs (n = 429) indicated that ginger was as effective as the reference drug (vitamin B6) in relieving the severity of nausea and vomiting episodes. The observational study retrieved and RCTs (including follow-up periods) showed the absence of significant side effects or adverse effects on pregnancy outcomes. There were no spontaneous or case reports of adverse events during ginger treatment in pregnancy.

CONCLUSION

Ginger may be an effective treatment for nausea and vomiting in pregnancy. However, more observational studies, with a larger sample size, are needed to confirm the encouraging preliminary data on ginger safety.

LEVEL OF EVIDENCE

I.

[Is ginger a clinically relevant antiemetic? A systematic review of randomized controlled trials]

BACKGROUND AND OBJECTIVE

The aim of this systematic review was to evaluate the clinical impact of ginger (Zingiber officinale) as an antiemetic.

METHODS

A systematic search of the literature was performed using the databases of MEDLINE, EMBASE, and the Cochrane-Library.

RESULTS

Of 100 published reports discerned as potentially relevant, 24 randomized controlled trials were evaluated, covering 1073 patients which had received ginger. Of these reports, 16 contained information regarding the antiemetic activity of the phytotherapeutic agent against kinetosis, postoperative nausea and vomiting (PONV), and morning sickness and hyperemesis gravidarum, respectively. Only a few studies were eligible for a quantitative analysis (meta-analysis). Thus, the majority of the reports were analyzed descriptively. To analyze the potential side effects of the drug, 15 reports with 777 patients were eligible. Of these, 3.3% suffered from slight side effects, mainly mild gastrointestinal symptoms and sleepiness, both not requiring specific treatments. One severe adverse event was reported in a study: an abortion occurred in the 12th week of gestation. However, a total of 136 patients were treated with ginger within the first trimenon of pregnancy without complications.

CONCLUSION

There is no clear evidence for the efficacy of ginger in the treatment of PONV and of kinetosis. The results for the treatment of nausea and vomiting in pregnancy are encouraging, however, ginger should be applied for the time being only in controlled clinical studies. Applied in daily doses up to 6 g ginger seems to be a drug with few side effects.

Clinical toxicology study of an herbal medicinal extract of Paullinia cupana, Trichilia catigua, Ptychopetalum olacoides and Zingiber officinale (Catuama) in healthy volunteers

In Brazil, a herbal medicinal extract named Catuama containing a mixture of Paullinia cupana (guarana; Sapindaceae), Trichilia catigua (catuaba; Meliaceae), Ptychopetalum olacoides (muirapuama; Olacaceae) and Zingiber officinale (ginger; Zingiberaceae) is used as a body stimulant, energetic, tonic and aphrodisiac. The present study investigated the chronic administration of 25 mL Catuama twice a day during 28 days for any toxic effect on healthy human volunteers of both sexes. No severe adverse reactions or haematological and biochemical changes were reported.

Nausea and vomiting in pregnancy: safety and efficacy of self-administered complementary therapies

Nausea and vomiting affects a large proportion of women in early pregnancy, yet because it is a physiological symptom it is often dismissed by health professionals, leaving women to find their own coping mechanisms. This leads many to try a range of complementary and alternative therapies and natural remedies, although the evidence of efficacy is variable. Furthermore, while women realise the possible risks of taking medication during pregnancy they do not see complementary medicine in the same way. This paper explores a few of the common alternatives which expectant mothers self-administer to relieve nausea and vomiting and addresses issues of efficacy and safety.

Effects of a ginger extract on knee pain in patients with osteoarthritis

OBJECTIVE

To evaluate the efficacy and safety of a standardized and highly concentrated extract of 2 ginger species, Zingiber officinale and Alpinia galanga (EV.EXT 77), in patients with osteoarthritis (OA) of the knee.

METHODS

Two hundred sixty-one patients with OA of the knee and moderate-to-severe pain were enrolled in a randomized, double-blind, placebo-controlled, multicenter, parallel-group, 6-week study. After washout, patients received ginger extract or placebo twice daily, with acetaminophen allowed as rescue medication. The primary efficacy variable was the proportion of responders experiencing a reduction in "knee pain on standing," using an intent-to-treat analysis. A responder was defined by a reduction in pain of > or = 15 mm on a visual analog scale.

RESULTS

In the 247 evaluable patients, the percentage of responders experiencing a reduction in knee pain on standing was superior in the ginger extract group compared with the control group (63% versus 50%; P = 0.048). Analysis of the secondary efficacy variables revealed a consistently greater response in the ginger extract group compared with the control group, when analyzing mean values: reduction in knee pain on standing (24.5 mm versus 16.4 mm; P = 0.005), reduction in knee pain after walking 50 feet (15.1 mm versus 8.7 mm; P = 0.016), and reduction in the Western Ontario and McMaster Universities osteoarthritis composite index (12.9 mm versus 9.0 mm; P = 0.087). Change in global status and reduction in intake of rescue medication were numerically greater in the ginger extract group. Change in quality of life was equal in the 2 groups. Patients receiving ginger extract experienced more gastrointestinal (GI) adverse events than did the placebo group (59 patients versus 21 patients). GI adverse events were mostly mild.

CONCLUSION

A highly purified and standardized ginger extract had a statistically significant effect on reducing symptoms of OA of the knee. This effect was moderate. There was a good safety profile, with mostly mild GI adverse events in the ginger extract group.

Integration of Chinese medicine into supportive cancer care: a modern role for an ancient tradition

Recent evidence suggests that many traditional Chinese medical therapies are effective for the supportive care of cancer patients. This is a review of some of the published literature (indexed in Medline) and our own practical experience. It is not intended to be a systematic review, but does provide various levels of evidence which support further research into a developing model of integrative care. The holistic approach of Traditional Chinese Medicine (TCM) may be integrated into conventional Western Medicine to supplement deficiencies in the current biomedical model. The philosophy of TCM proposes novel hypotheses which will support the development of a science-based holistic medicine.

Herbal Therapy

Herbal medicine (phytomedicine) uses remedies possessing significant pharmacological activity and, consequently, potential adverse effects and drug interactions. The explosion in sales of herbal therapies has brought many products to the marketplace that do not conform to the standards of safety and efficacy that physicians and patients expect. Unfortunately, few surgeons question patients regarding their use of herbal medicines, and 70% of patients do not reveal their use of herbal medicines to their physicians and pharmacists. All surgeons should question patients about the use of the following common herbal remedies, which may increase the risk of bleeding during surgical procedures: feverfew, garlic, ginger, ginkgo, and Asian ginseng. Physicians should exercise caution in prescribing retinoids or advising skin resurfacing in patients using St John's wort, which poses a risk of photosensitivity reaction. Several herbal medicines, such as aloe vera gel, contain pharmacologically active ingredients that may aid in wound healing. Practitioners who wish to recommend herbal medicines to patients should counsel them that products labeled as supplements have not been evaluated by the US Food and Drug Administration and that no guarantee of product quality can be made.

The diagnosis and treatment of dizziness

Dizziness is a complex and frustrating symptom of potentially numerous causes. The history and physical examination can elicit the category that best characterizes the dizziness: vertigo, presyncope, dysequilibrium, or lightheadedness. If the cause of dizziness cannot be found or treated directly, medications may suppress symptoms. Surgery for vertigo includes conservative and destructive procedures. Rehabilitation is often a useful adjunct in the treatment of many types of dizziness.

The role of plant-derived drugs and herbal medicines in healthcare

Many of our present medicines are derived directly or indirectly from higher plants. While several classic plant drugs have lost much ground to synthetic competitors, others have gained a new investigational or therapeutical status in recent years. In addition, a number of novel plant-derived substances have entered into Western drug markets. Clinical plant-based research has made particularly rewarding progress in the important fields of anticancer (e.g. taxoids and camptothecins) and antimalarial (e.g. artemisinin compounds) therapies. In addition to purified plant-derived drugs, there is an enormous market for crude herbal medicines. Natural product research can often be guided by ethnopharmacological knowledge, and it can make substantial contributions to drug innovation by providing novel chemical structures and/or mechanisms of action. In the end, however, both plant-derived drugs and crude herbal medicines have to take the same pharmacoeconomic hurdle that has become important for new synthetic pharmaceuticals.

Zingiber officinale (ginger)--an antiemetic for day case surgery

The effect of powdered ginger root was compared with metoclopramide and placebo. In a prospective, randomised, double-blind trial the incidence of postoperative nausea and vomiting was measured in 120 women presenting for elective laparoscopic gynaecological surgery on a day stay basis. The incidence of nausea and vomiting was similar in patients given metoclopramide and ginger (27% and 21%) and less than in those who received placebo (41%). The requirement for postoperative antiemetics was lower in those patients receiving ginger. The requirements for postoperative analgesia, recovery time and time until discharge were the same in all groups. There was no difference in the incidence of possible side effects such as sedation, abnormal movement, itch and visual disturbance between the three groups. Zingiber officinale is an effective and promising prophylactic antiemetic, which may be especially useful for day case surgery.

Zingiber officinale does not affect gastric emptying rate. A randomised, placebo-controlled, crossover trial

The effect of the powdered rhizome of Zingiber officinale (ginger root) on the gastric emptying rate was investigated. In a double-blind crossover trial, 16 healthy volunteers were randomly allocated to receive either 1 g of ginger or placebo. Gastric emptying was measured using the oral paracetamol absorption model. Ingestion of ginger did not effect gastric emptying. The antiemetic effect of ginger is not associated with an effect on gastric emptying. No adverse effects were noted.

Travel medicine. General advice and medical kit

Physicians must be prepared to provide comprehensive pretravel advice to their patients. Because world conditions are constantly changing, it is necessary to obtain accurate and current information. Common health problems that may be faced by any traveler include accidents, motion sickness, and jet lag. Physicians must familiarize themselves with the many forms of insurance available for the traveler.

Ginger root--a new antiemetic. The effect of ginger root on postoperative nausea and vomiting after major gynaecological surgery

The effectiveness of ginger (Zingiber officinale) as an antiemetic agent was compared with placebo and metoclopramide in 60 women who had major gynaecological surgery in a double-blind, randomised study. There were statistically significantly fewer recorded incidences of nausea in the group that received ginger root compared with placebo (p less than 0.05). The number of incidences of nausea in the groups that received either ginger root or metoclopramide were similar. The administration of antiemetic after operation was significantly greater in the placebo group compared to the other two groups (p less than 0.05).

The anti-motion sickness mechanism of ginger. A comparative study with placebo and dimenhydrinate

A controlled, double-blind study was carried out to determine whether nystagmus response to optokinetic or vestibular stimuli might be altered by some agent contained in powdered ginger root (Zingiber officinale). For comparative purposes, the test subjects were examined after medication with ginger root, placebo and with dimenhydrinate. Eye movements were recorded using standard ENG equipment and evaluation was performed by automatic nystagmus analysis. It could be demonstrated that the effect of ginger root did not differ from that found at baseline, or with placebo, i.e. it had no influence on the experimentally induced nystagmus. Dimenhydrinate, on the other hand, was found to cause a reduction in the nystagmus response to caloric, rotatory and optokinetic stimuli. From the present study it can be concluded that neither the vestibular nor the oculomotor system, both of which are of decisive importance in the occurrence of motion sickness, are influenced by ginger. A CNS mechanism, which is characteristic of the conventional anti-motion sickness drugs, can thus be excluded as regards ginger root. It is more likely that any reduction of motion-sickness symptoms derives from the influence of the ginger root agents on the gastric system.

Ginger root against seasickness. A controlled trial on the open sea

In a double-blind randomized placebo trial, the effect of the powdered rhizome of ginger (Zingiber officinale) was tested on seasickness. Eighty naval cadets, unaccustomed to sailing in heavy seas reported during voyages on the high seas, symptoms of seasickness every hour for 4 consecutive hours after ingestion of 1 g of the drug or placebo. Ginger root reduced the tendency to vomiting and cold sweating significantly better than placebo did (p less than 0.05). With regard to vomiting, a modified Protection Index (PI) = 72% was calculated. Remarkably fewer symptoms of nausea and vertigo were reported after ginger root ingestion, but the difference was not statistically significant. For all symptom categories, PI = 38% was calculated.