Acupuncture For Refractory Cases Of
Chemotherapy-Induced Nausea And Vomiting
Maria del C. Guerra, MD
Background Chemotherapy-induced nausea and vomiting are thought to be caused by serotonin release. Because acupuncture may interact with serotonin, this modality has been postulated to help alleviate chemotherapy-induced nausea and vomiting.
Objective To describe the use of acupuncture for treating a series of patients with cancer who received chemotherapy and experienced nausea and vomiting.
Design, Setting, and Patients Eight patients presented to the author's practice (in 1998-1999) for acupuncture treatment. Each of the patients had experienced nausea and vomiting as the result of at least 1 course of chemotherapy.
Intervention Acupuncture needling at PC 6, ST 43, GV 20, and CV 12; ST 36 was used if this point was tender. Patients also received antiemetic pharmacotherapy as they had prior to the acupuncture treatment.
Main Outcome Measure Cessation of chemotherapy-induced nausea and vomiting.
Results Seven of the 8 patients responded to the addition of acupuncture to control nausea and vomiting. These patients generally were able to tolerate additional courses of chemotherapy.
Conclusion Acupuncture may be an effective tool for helping to alleviate chemotherapy-induced nausea and vomiting in patients refractory to standard premedication.
Nausea, Vomiting, Chemotherapy, Acupuncture
Chemotherapy-induced nausea and vomiting is caused by the release of serotonin from the enterochromaffin cells of the small intestine. This stimulates the serotonin receptors of the gastrointestinal tract and the chemoreceptor trigger zone in the cortex of the brain. Ultimately, the medullary vomiting center is activated to initiate the vomiting reflex. Acute nausea and vomiting usually starts within 2 hours after chemotherapy administration, peaks at 4-10 hours, and then subsides 12-24 hours later.
The use of serotonin receptor antagonists to control nausea and vomiting has markedly improved the quality of life for patients with cancer undergoing chemotherapy. There is extensive literature and various guidelines1-3 governing the use of these agents. Unfortunately, some patients do not respond to these agents and continue to experience nausea and vomiting. Some of these patients require hospitalization as a result of the sequelae (e.g., dehydration) which adversely affects the quality of life and increases overall expenses for treatment. In addition, serotonin receptor antagonists are very expensive. Ultimately, some patients decline continued chemotherapy because of its adverse effects, although the chemotherapy has a favorable effect on their cancers.
Patients with a history of hyperemesis gravidarum and motion sickness are often predisposed to experience chemotherapy-induced nausea and vomiting, even when these patients are given antiemetic agents prior to treatment. Another small group of patients with carcinomatosis (e.g., ovarian) often present with nausea prior to the administration of chemotherapeutic agents.
Acupuncture has been used to treat nausea and vomiting caused by pregnancy4 or postoperative surgery.5 Chemotherapy-induced nausea and vomiting has been treated by using only the PC 6 (Neiguan) point without pharmacotherapy.6,7 Control of chemotherapy-induced nausea and vomiting has lasted from 1-4 hours and in a few cases up to 48 hours. The efficacy of electroacupuncture for patients receiving high-dose chemotherapy was demonstrated recently in a randomized controlled trial.8
A possible mechanism of action is that acupuncture facilitates
5-HT release in the brain, which then activates the descending inhib-itory fibers which interferes with 5-HT release in the spinal cord.9
Eight patients were scheduled to receive chemotherapy from January 1998 to February 1999. All of these patients received at least 1 prior course of chemotherapy that produced moderate to severe nausea and vomiting, despite pretreatment with a steroid (dexamethasone), serotonin antagonist (ondansetron), and sedation (lorazepam).2 Therefore, these patients served as their own controls. Acupuncture was performed by the author, following a protocol suggested by Joseph Helms, MD, as an individual adviser. Patient consent was obtained and IRB approval was not required.
The intervention consisted of pharmacological pretreatment identical to that provided during the patient's prior course of chemotherapy, followed by a simple acupuncture protocol (not electroacupuncture). All patients were needled bilaterally at PC 6 and at ST 43, 1 needle at GV 20 and at CV 12, and ST 36 (this point was needled only if tender) bilaterally. Most of the points were needled using shallow insertion with "J" type size No. 5 (0.25 x 40 mm with tubes Seirin needles (Seirin America Inc., Weymouth, MA); CV 12 and ST 36 were needled deep, perpendicular until patient experienced the Qi sensation. The needles were left in for 15-20 minutes.
Approximately 5 minutes prior to the removal of the needles, PC 6 was manually tonified (twirled clockwise). Within 30 minutes of the removal of the needles, patients received their respective chemotherapy. Acupuncture treatment was repeated on the 4th day only if chemotherapy was administered for more than 3 consecutive days.
Acupuncture Points Used
- CV 12 Harmonizes the stomach and downbears the counterflow; the alarm-MU point of the stomach and meeting Hue point of the hollow organs
- PC 6 Downbears the counterflow, stops vomiting, harmonizes the stomach
- ST 43 Harmonizes the stomach and downbears the counterflow
- GV 20 Intersection point of the 6 Yang channels and Governing Vessel
- ST 36 Regulates central Qi, rectifies the spleen and stomach, stops vomiting.
A 49-year-old woman with stage II breast cancer that was estrogen and progesterone receptor negative received 2 courses of adjuvant chemotherapy consisting of doxorubicin and cyclophosphamide.
She had experienced severe nausea and vomiting for 10 days and had other adverse effects that required hospitalization. The patient refused further chemotherapy with the same agents. After a single course of cyclophosphamide, methotrexate, and fluorouracil, the patient again experienced severe nausea and vomiting and was hospitalized for severe dehydration. All chemotherapy was stopped. Four months later, the patient returned with liver metastasis. The patient received 3 courses of docetaxel and doxorubicin and acupuncture was added to the antiemetic pretreatment regimen. This patient tolerated all 3 courses of chemotherapy without complications.
A 53-year-old woman with stage II breast cancer was treated with adjuvant cyclophosphamide, methotrexate, and fluorouracil (per patient preference) although doxorubicin was recommended. The patient received 4 courses of this regimen followed by radiotherapy The same antiemetic premedications (ondansetron, dexamethasone, and lorazepam) had been administered to her for all courses of her chemotherapy. However, during the 5th course, she had severe nausea and vomiting. Acupuncture was added to the antiemetic protocol and this patient was able to complete chemotherapy without further nausea or vomiting.
A 42-year-old woman with stage II-B breast cancer who had a lumpectomy, had 9 of 11 positive lymph nodes, and was estrogen receptor-positive. She was given 4 cycles of adjuvant chemotherapy containing doxorubicin. She subsequently received 8 cycles of cyclophosphamide, methotrexate, and fluorouracil. One year later, she developed a solitary spinal lesion in L1 and was treated by radiotherapy followed by 2 courses of docetaxel and doxorubicin. The patient complained of severe nausea and vomiting, despite antiemetic premedications. Several lumbar puncture studies revealed no carcinomatosis. Acupuncture was added to the antiemetic regimen, but did not reduce her complaints of nausea and vomiting, which only ceased when doxorubicin was discontinued.
A 51-year-old patient with stage III-B gastric carcinoma received chemotherapy consisting of adjuvant fluorouracil, mitomycin, and doxorubicin. The patient decided to stop chemotherapy due to nausea and vomiting. Two years later, the patient had recurrence in the retroperitoneum and complained of severe back pain. After premedicating the patient with ondansetron and dexamethasone, a course of cisplatin, doxorubicin, fluorouracil, and leucovorin was given. The patient was admitted to the hospital for intractable nausea and vomiting. Acupuncture was administered in addition to the previous routine premedications and the patient was able to tolerate 4 more courses of chemotherapy.
A 61-year-old woman with stage III ovarian cancer presented with ascites and nausea. This patient had a history of severe motion sickness. Acupuncture was added to her premedication regimen of cyclophosphamide and cisplatin. The patient had a good response and was able to continue chemotherapy for 6 months. Notably, GV 20 was omitted after the 2nd course because the patient complained of headache after acupuncture. Five months later, paclitaxel and cyclophosphamide were started because of recurrence. Acupuncture was included along with her premedication regimen. The patient received 4 courses with a good response. She received her 5th cycle of chemotherapy at a different clinic and acupuncture was not included in her pretreatment regimen. As a consequence, she was hospitalized for severe chemotherapy-induced nausea and vomiting. She returned to our clinic and received 6 more courses of chemotherapy, along with acupuncture, and did not experience any further nausea or vomiting.
A 54-year-old woman with stage II breast cancer received adjuvant chemotherapy with adriamycin and cytoxan. She experienced severe nausea and vomiting despite receiving standard antiemetic premedication. Although she wanted to discontinue further chemotherapy,
she agreed to a regimen of cyclophosphamide, methotrexate, and fluorouracil. After the 1st course, she again experienced nausea and vomiting. Acupuncture was added to her premedication and she was able to tolerate 4 additional courses of chemotherapy.
A 62-year-old woman with stage IV ovarian carcinoma with ascites, pleural effusion, and nausea on presentation. Acupuncture was added to the antiemetic regimen before carboplatin was given. The patient successfully completed 6 courses of chemotherapy without any nausea or vomiting.
A 34-year-old woman had non-Hodgkin lymphoma of the mediastinum. After the 1st course of cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP), the patient was hospitalized for severe dehydration caused by nausea and vomiting. Acupuncture was performed during the 3rd hospital day and the nausea and vomiting resolved. Acupuncture was added to the antiemetic premedication regimen in her subsequent chemotherapy cycles and she was able to tolerate an additional 5 courses of CHOP.
In 7 of the 8 cases presented, acupuncture proved to be a useful adjunct modality to reduce chemotherapy-induced nausea and vomiting. This preliminary report suggests that in selected patients who are refractory to standard premedications with steroids, serotonin receptor antagonist, and sedatives (intravenous dexamethasone, ondansetron, and lorazepam), or who have nausea at presentation (carcinomatosis) or strong past history of motion sickness or hyperemesis gravidarum, acupuncture may be a useful and effective addition to the currently available treatments to prevent chemotherapy-induced nausea and vomiting.
Fewer hospitalizations for treating nausea and vomiting would improve patients' quality of life and reduce treatment costs. In addition, this approach may improve tolerance and compliance with chemotherapy, which could improve clinical outcomes in patients with cancer. In this particular protocol, the treatment is needed only once, just before the chemotherapy is administered, with very few exceptions (when chemotherapy is given for 5 consecutive days, the acupuncture is repeated on the 3rd day). Future controlled studies would be useful in comparing to other acupuncture protocols in treating refractory nausea and vomiting related to chemotherapy.
Thank you to Mitchell Goldbaum, MD, for his comments and support, and to Linda Maynor, Oncology RN, and Raymond Jung, PharmD Oncology, for their collaboration.
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- Audhuy B, Cappelaere P, Martin M, et al. A double-blind randomised comparison of the anti-emetic efficacy of two intravenous doses of dolasetron mesilate and granisetron in patients receiving high dose cisplatin chemotherapy. Eur J Cancer. 1996;32A:807-813.
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Dr Maria Guerra is certified by the Board of Internal Medicine and has specialized in Hematology-Oncology for 20 years. Dr Guerra practices in a large multidisciplinary institution in the South Bay Area, California.
Maria del C. Guerra, MD, DABMA*
Rolling Hills Estates
PO Box 329
Los Angeles, CA 90274
*Correspondence and reprint requests