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Acupuncture-point stimulation for chemotherapy-induced nausea or vomiting: Cochrane systematic review

Abstract

Assessed as up to date: 2006/02/21

Background

There have been recent advances in chemotherapy-induced nausea and vomiting using 5-HT3 inhibitors and dexamethasone. However, many still experience these symptoms, and expert panels encourage additional methods to reduce these symptoms.

Objectives

The objective was to assess the effectiveness of acupuncture-point stimulation on acute and delayed chemotherapy-induced nausea and vomiting in cancer patients.

Search methods

We searched MEDLINE, EMBASE, PsycLIT, MANTIS, Science Citation Index, CCTR (Cochrane Controlled Trials Registry), Cochrane Complementary Medicine Field Trials Register, Cochrane Pain, Palliative Care and Supportive Care Specialized Register, Cochrane Cancer Specialized Register, and conference abstracts.

Selection criteria

Randomized trials of acupuncture-point stimulation by any method (needles, electrical stimulation, magnets, or acupressure) and assessing chemotherapy-induced nausea or vomiting, or both.

Data collection and analysis

Data were provided by investigators of the original trials and pooled using a fixed effect model. Relative risks were calculated on dichotomous data. Standardized mean differences were calculated for nausea severity. Weighted mean differences were calculated for number of emetic episodes.

Main results

Eleven studies (N = 1247) were pooled. Overall, acupuncture-point stimulation of all methods combined reduced the incidence of acute vomiting (RR = 0.82; 95% confidence interval (CI) 0.69 to 0.99; P = 0.04), but not acute or delayed nausea severity compared to control. By modality, stimulation with needles reduced proportion of acute vomiting (RR = 0.74; 95% CI 0.58 to 0.94; P = 0.01), but not acute nausea severity. Electroacupuncture reduced the proportion of acute vomiting (RR = 0.76; 95% CI 0.60 to 0.97; P = 0.02), but manual acupuncture did not; delayed symptoms for acupuncture were not reported. Acupressure reduced mean acute nausea severity (SMD = -0.19; 95% CI -0.37 to -0.01; P = 0.04) but not acute vomiting or delayed symptoms. Noninvasive electrostimulation showed no benefit for any outcome. All trials used concomitant pharmacologic antiemetics, and all, except electroacupuncture trials, used state-of-the-art antiemetics.

Authors' conclusions

This review complements data on post-operative nausea and vomiting suggesting a biologic effect of acupuncture-point stimulation. Electroacupuncture has demonstrated benefit for chemotherapy-induced acute vomiting, but studies combining electroacupuncture with state-of-the-art antiemetics and in patients with refractory symptoms are needed to determine clinical relevance. Self-administered acupressure appears to have a protective effect for acute nausea and can readily be taught to patients though studies did not involve placebo control. Noninvasive electrostimulation appears unlikely to have a clinically relevant impact when patients are given state-of-the-art pharmacologic antiemetic therapy.

Author(s)

Ezzo Jeanette, Richardson Mary Ann, Vickers Andrew, Allen Claire, Dibble Suzanne, Issell Brian F, Lao Lixing, Pearl Michael, Ramirez Gilbert, Roscoe Joseph A, Shen Joannie, Shivnan Jane C, Streitberger Konrad, Treish Imad, Zhang Grant, Manheimer Eric

Summary

Acupuncture for nausea and vomiting which has been induced by having chemotherapy treatment

This review looked at whether stimulating acupuncture points could reduce nausea and vomiting caused by chemotherapy. Acupuncture points can be stimulated by acupuncture applied with electricity (electroacupuncture), acupuncture without electricity (manual acupuncture), acupressure (pressing on the points usually with fingertip), or electrical stimulation on the skin surface such as wristwatch-like devices. Electroacupuncture reduced first-day vomiting, but manual acupuncture did not. Acupressure reduced first-day nausea, but was not effective on later days. Acupressure showed no benefit for vomiting. Electrical stimulation on the skin showed no benefit. All trials also gave anti-vomiting drugs, but the drugs used in the electroacupuncture trials were not the most modern drugs, so it is not known if electroacupuncture adds anything to modern drugs. Trials of electroacupuncture with modern drugs are needed.

Reviewer's Conclusions

Implications for practice

This review complements data on post-operative nausea and vomiting suggesting a biologic effect of acupuncture-point stimulation. Electroacupuncture has demonstrated benefit for chemotherapy-induced acute vomiting, but studies with state-of-the-art antiemetics as well as studies for refractory symptoms are needed to determine clinical relevance. Acupressure appears to reduce chemotherapy-induced acute nausea severity, though studies did not involve a placebo control. Noninvasive electrostimulation appears unlikely to have a clinically relevant impact when patients are given state-of-the-art pharmacologic antiemetic therapy. Neither electrostimulation nor acupressure offered significant relief for delayed symptoms, and acupuncture delayed data were not available. Acupuncture-point stimulation by any method is safe with minimal, transient, and rare side effects.

Implications for research

The most important research question emerging from this review is whether or not electroacupuncture combined with current antiemetics can offer additional benefit for those chemotherapy patients with refractory symptoms. Our review has raised the question of effective dose, e.g. whether stimulating more than one acupuncture-point and doing so continuously for 20 minutes can provide a greater effect that stimulating one point and leaving needles in place without continuous stimulation. These dosing questions should be examined in smaller dosing studies prior to a large trial.

Additionally, the existing literature provides some considerations for use in trial design:
(1) electroacupuncture is more effective when given before rather than after symptoms occur;
(2) electroacupuncture above 5 - 15Hz can be counterproductive, even exacerbating symptoms, so a lower electrical frequency is suggested (Dundee 1988a); and
(3) electroacupuncture antiemetic benefits last about eight hours (Dundee 1987). One study has demonstrated that combining electroacupuncture with subsequent acupressure can prolong electroacupuncture benefits (Dundee 1990a), and this combined-modality research could help address the inconvenience of the short duration of benefit with acupuncture.

The important research outcomes are acute and delayed nausea and vomiting. Therefore, a single-infusion chemotherapy regimen (rather than multiday) with a five-to seven-day follow up would be optimal to separate acute from delayed symptoms and assess acupuncture's relative impact on each. Use of a sham control is important, and the placebo needle (Streitberger 1998) would allow both real and sham treatments to use the same points and also to eliminate concerns about non-specific needling effects. If acupressure were added as a method to prolong treatment effects, a sham acupressure control would also be warranted.

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Citation

"Acupuncture-point Stimulation for Chemotherapy-induced Nausea or Vomiting: Cochrane Systematic Review." Cochrane Abstracts, Evidence Central, evidence.unboundmedicine.com/evidence/view/Cochrane/433200/all/Acupuncture_point_stimulation_for_chemotherapy_induced_nausea_or_vomiting:_Cochrane_systematic_review. Accessed 22 July 2019.
Acupuncture-point stimulation for chemotherapy-induced nausea or vomiting: Cochrane systematic review. Cochrane Abstracts. https://evidence.unboundmedicine.com/evidence/view/Cochrane/433200/all/Acupuncture_point_stimulation_for_chemotherapy_induced_nausea_or_vomiting:_Cochrane_systematic_review. Accessed July 22, 2019.
Acupuncture-point stimulation for chemotherapy-induced nausea or vomiting: Cochrane systematic review. In Cochrane Abstracts. Available from https://evidence.unboundmedicine.com/evidence/view/Cochrane/433200/all/Acupuncture_point_stimulation_for_chemotherapy_induced_nausea_or_vomiting:_Cochrane_systematic_review
Acupuncture-point Stimulation for Chemotherapy-induced Nausea or Vomiting: Cochrane Systematic Review [Internet]. In: Cochrane Abstracts. [cited 2019 July 22]. Available from: https://evidence.unboundmedicine.com/evidence/view/Cochrane/433200/all/Acupuncture_point_stimulation_for_chemotherapy_induced_nausea_or_vomiting:_Cochrane_systematic_review.
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TY - ELEC T1 - Acupuncture-point stimulation for chemotherapy-induced nausea or vomiting: Cochrane systematic review ID - 433200 BT - Cochrane Abstracts UR - https://evidence.unboundmedicine.com/evidence/view/Cochrane/433200/all/Acupuncture_point_stimulation_for_chemotherapy_induced_nausea_or_vomiting:_Cochrane_systematic_review DB - Evidence Central DP - Unbound Medicine ER -