Running head: DECREASING NAUSEA AND VOMITING
Decreasing Nausea and Vomiting
Shelby DeLoach
University of South Florida
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DECREASING NAUSEA AND VOMITING
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Abstract
Clinical Problem: Patients undergoing chemotherapy are likely to experience nausea and
vomiting as result of chemotherapy administration, which decreases patient comfort throughout
treatment.
Objective: To determine if the use of acupuncture or acupressure will minimize the occurrence of
nausea and vomiting in cancer patients receiving chemotherapy treatments. National Guide
Clearinghouse, PubMed, and CINAHL were approached to acquire guidelines and randomized
controlled trials regarding decreasing occurrence of nausea and vomiting in patients undergoing
chemotherapy. The key terms utilized were nausea, vomiting, antiemetic, acupuncture,
acupressure, cancer, and chemotherapy.
Results: According to Rithirangsriroj, Manchana, and Akkayagorn (2014), the utilization of
acupuncture versus ondanestron delayed the onset of nausea and vomiting as well as increased
the participants’ quality of life for those receiving the acupuncture interventions. Research
produced by Tas, Uncu, Sendur, Koca, and Zengin (2014), determined participant’s experienced
less nausea and vomiting, pain, insomnia, and anxiety. According to the investigation conducted
by Yeh et al. (2012) patients who undergo either auricular pressure with standard care or sham
auricular acupuncture experience a decreased incidence of nausea and vomiting. Tipton et al.
(2011) recommends the use of behavioral therapies and pharmacological interventions for the
management of chemotherapy-induced nausea and vomiting.
Conclusion: Cancer patients who receive acupuncture or acupressure therapies in addition to the
administration of antiemetics during chemotherapy treatments will have reduced episodes of
nausea and vomiting. Further research is needed to determine if these interventions are effective
on a large sample size.
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Decreasing Nausea and Vomiting
According to Tipton et al. (2011) the management of nausea and vomiting in
chemotherapy patients persists to be an issue regardless of advances in medications.
Chemotherapy-induced nausea and vomiting has poor outcomes for patients including lack of
compliance, early termination of treatment, and poor quality of life (Rithirangsriroj, Manchana,
and Akkayagorn 2014). Determining the benefits of this treatment will allow for better patient
care and increased comfort. Current guidelines for the management of chemotherapy-induced
nausea and vomiting state that both acupressure and acupuncture are likely to effective (Tipton et
al., 2011). This paper assesses effectiveness of acupuncture and acupressure as a method of
managing nausea and vomiting in chemotherapy patients. In patients undergoing chemotherapy,
how does acupuncture and acupressure therapy and medication compared to medication alone
decrease the occurrence of nausea and vomiting, during a three-month period of treatment?
Literature Search
National Guide Clearinghouse, PubMed, and CINAHL were approached to acquire
guidelines and randomized controlled trials regarding decreasing occurrence of nausea and
vomiting in patients undergoing chemotherapy. The key terms utilized were nausea, vomiting,
antiemetic, acupuncture, acupressure, cancer, and chemotherapy.
Literature Review
Three randomized controlled trials and one guideline were utilized to evaluate the
usefulness of acupuncture or acupressure in addition to medication for patients undergoing
chemotherapy (Table 1). Rithirangsriroj et al. (2014) developed a controlled crossover study to
evaluate the benefit of acupuncture in delaying chemotherapy-induced nausea and vomiting. The
trial included 70 participants randomized into two different groups. The criteria for patients to
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participate in this study were that they were younger than 70, a Karnofsky score of 80%, and that
they were receiving first line chemotherapy treatments. The study excluded patients with the
following reasons but not limited to vomiting in the last 24 hours, taking any antiemetic drugs in
the last 24 hours, patients who exhibit characteristics of brain metastasis, and bowel obstruction.
Of the two randomized groups, one group received one 8-milligram dose of ondansetron 30
minutes before chemotherapy treatment and the other group received manual acupuncture 30
minutes before chemotherapy treatment and the day after chemotherapy treatment. Both groups
of patients were allowed 4 milligram of oral ondansetron every 12 hours to manage nausea and
vomiting and all patients received oral dexamethasone two times a day for the first three days of
the study. All of the patients were evaluated for three-weeks. The end results were that the
acupuncture group experienced higher delays in nausea than the group being administered
ondansetron (P=0.004). The acupuncture group encountered less nausea and vomiting in delayed
onset (P=0.04 and P<0.001). The strengths of this study are that it was a randomized, crossover
study with 70 participants, which is good sample size for this study. The weakness of the study
was that all of the participants were administered the same chemotherapy medications for
consistency, which does not allow for researchers to see if other chemotherapy medications
would have affected participants differently. The study receives a recommendation grade of A
due to strong evidence in support of the interventions and minimal risks associated.
Tas, Uncu, Sendur, Koca, and Zengin (2014) conducted a well-designed study to
determine if acupuncture would alleviate the side effects associated with chemotherapy for
cancer patients. The side effects evaluated in this study are pain, nausea, vomiting, sleep quality,
and anxiety. There were 45 participants selected for this study and the demographics of the
participants were not considered for selection. Patients were not eligible for specific reasons
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including but not limited to if they had any signs of infection, high fever, or thrombocytopenia.
Acupuncture was administered on the day chemotherapy was given as well as one day before
and after treatments for a total of 3 days. Patients were assessed using a scale of 0 to 4 for nausea
and vomiting, a pain scale, and an insomnia severity scale. The results of the study yielded a
decrease in the nausea, vomiting, insomnia, pain score, and anxiety in the participants receiving
acupuncture (p<0.001). The strengths of the trial were good demographics of participants
including both male and female participants, those receiving different chemotherapy treatments,
multiples types of cancers, and varying stages. The weaknesses of the trial were that it was not
randomized, however, this study was still well designed. This study provided strong evidence but
due to lack of randomization in this study, the recommendation grade is B.
Yeh et al. (2012) determined if the use of acupuncture in addition to standard care would
reduce nausea and vomiting in children during the course of their chemotherapy treatments. This
study was conducted on 10 patients using three rounds of chemotherapy. For the first cycle of
chemotherapy, the patients underwent chemotherapy with no additional interventions. For the
second cycle of chemotherapy, patients were randomly placed into two groups, one was auricular
acupressure with regular standard care and other group was auricular acupressure using sham
points with regular standard care. During the third cycle, the groups swapped interventions. In
addition to the acupressure, each of the patients were also taking medication to treat
chemotherapy-induced nausea and vomiting beginning at the induction of treatment and the
amount of medication administered was decreased throughout the trials. The criteria for patients
to participate was based on age, previous treatment, duration of previous treatment, prescribed
medications, and if patients had received acupuncture or acupressure in the past. Patients were
assessed for 7 days following each round of chemotherapy, for a total of 21 days. The results
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yield that patients who undergo auricular acupressure with regular standard care had a lower
incidence of nausea (p=0.0289) and vomiting (p=0.0024) than patients receiving standard care
alone. Participants undergoing sham auricular acupuncture experience a decreased incidence of
vomiting (p=0.0172) but there was no significant different in the occurrence of nausea
(p=0.1058) in comparison to those receiving only standard care. There was no significant
difference in occurrence of nausea (p=0.2590) and vomiting (p=0.1775) between participants
that received auricular acupuncture or sham auricular acupuncture. The strengths of this study
were that it is a crossover randomized controlled study and each group experienced both of the
interventions. The weakness was the small sample size utilized in this study. The
recommendation grade is A as the results and evidence are valid.
The guidelines for preventing, managing, and treating chemotherapy-induced nausea and
vomiting were acquired from the National Guidelines Clearinghouse and the Oncology Nursing
Society, implementing evidence-based interventions (Tipton et al., 2011). The Oncology Nursing
Society recommends behavioral therapies such as progressive muscle relaxation, acupressure,
guided imagery, and acupuncture. In addition, several pharmacological interventions are
recommended including corticosterioids and antipsychotics for the management of
chemotherapy-induced nausea and vomiting.
Synthesis
According the Rithirangsriroj et al. (2014), the utilization of acupuncture versus
ondanestron delayed the onset of nausea (P=0.04) and vomiting (P<0.001) as well as increased
the patient’s quality of life (P=0.004). Research produced by Tas et al. (2014), determined
participants receiving the acupuncture experienced less nausea and vomiting, pain, insomnia, and
anxiety (p<0.001). According to the investigation conducted by Yeh et al. (2012) patients who
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undergo either auricular pressure with standard care or sham auricular acupuncture experience a
decreased incidence of nausea and vomiting. Participants who undergo auricular acupressure
with standard care had a lower incidence of nausea (p=0.0289) and vomiting (p=0.0024) than
patients receiving standard care alone. Participants undergoing sham auricular acupuncture
experience a decreased incidence of nausea (p=0.1058) and vomiting (p=0.0172) in comparison
to only standard care. Tipton et al. (2011) recommends the use of behavioral therapies and
pharmacological interventions for the management of chemotherapy-induced nausea and
vomiting.
The research produced indicates that acupuncture and acupressure both can be utilized to
reduce the occurrence of chemotherapy-induced nausea and vomiting. Tas et al. (2014) and
Rithirangsriroj et al. (2014) included sample sizes that were able to produce results that
demonstrated the effectiveness of acupuncture in reducing the side effects of nausea and
vomiting. Yeh et al. (2012) included a sample size of 10 patients, after 6 patients were excluded
and 6 patients dropped out. The number of participants affected the results of the study, as they
were not able to determine if auricular pressure with standard care or sham auricular acupuncture
was more affective for reducing side effects of nausea (p=0.2590) and vomiting (p=0.1775).
However, it was determined that both interventions independently did decrease the incidence of
nausea and vomiting in participants.
The recommendation grade of the overall evidence provided would earn the
recommendation of a B. This recommendation is based on the need for further research. The
studies utilized do not confirm absolute effectiveness of acupuncture or acupressure for
managing nausea and vomiting in addition to antiemetics for all chemotherapy treatments. There
are several types of chemotherapy treatments and cancers that are not represented in these
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studies.
Clinical Recommendations
The current guidelines by the Oncology Nursing Society indicate that the recommended
practice for managing the chemotherapy-induced nausea and vomiting is medication (Tipton et
al., 2011). The medications currently recommended include benzodiazapines, corticosterioids,
and antipsychotics. The guidelines also indicate that behavioral therapies including both
acupuncture and acupressure are likely to be effective as well. Acupuncture and acupressure are
favorable interventions for managing chemotherapy-induced nausea and vomiting and to
increase patient comfort.
Interventions recommended for practice include evidence that is supported by at least two
randomized controlled trials that includes at least 100 participants (Tipton et al., 2011). A
randomized controlled trial that observed a sample size of at least 100 participants after
exclusions would increase the validity of the current research. In addition, to a large sample size,
a study that monitored additional types of cancers and chemotherapy treatments would
strengthen this research. The overall utilization of medication therapy combined with
acupuncture or acupressure will help improve patient outcomes and increase patient comfort and
satisfaction.
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References
Rithirangsriroj, K., Manchana, T., & Akkayagorn, L. (2014). Efficacy of acupuncture in
prevention of delayed chemotherapy induced nausea and vomiting in gynecologic cancer
patients. Gynecologic Oncology, 136, 82-86. doi:10.1016/j.ygyno.2014.10.025.
Tas, D., Uncu, D., Sendur, M.A., Koca, N., & Zengin, N. (2014). Acupuncture as a
complementary treatment for cancer patients receiving chemotherapy. Asian Pacific
Journal of Cancer Prevention, 15(7), 3139-3144. doi:10.7314/APJCP.2014.15.7.3139
Tipton, J., Mcdaniel, R., Barbour, L., Johnston, M., Kayne, M., Leroy, P., & Ripple, M. (2011).
Putting evidence into practice: Evidence-based interventions to prevent, manage, and
treat chemotherapy-induced nausea and vomiting. Clinical Journal of Oncology Nursing,
11(1), 69-78. doi:10.1188/07.CJON.69-78
Yeh, C., Chien, L., Chiang, Y., Lin, S., Huang, C., & Ren, D. (2012). Reduction in nausea and
vomiting in children undergoing cancer chemotherapy by either appropriate or sham
auricular acupuncture points with standard care. The Journal of Alternative and
Complementary Medicine, 18(40), 334-340. doi:10.1089/acm.2011.0102
DECREASING NAUSEA AND VOMITING
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Table 1
Literature Review
Reference
Aims
Rithirangsriroj, K.,
Manchana, T., &
Akkayagorn, L. (2014).
Efficacy of acupuncture in
prevention of delayed
chemotherapy induced
nausea and vomiting in
gynecologic cancer patients.
Gynecologic Oncology, 136,
82-86.
doi:10.1016/j.ygyno.2014.10.
025.
To evaluate the
benefit of
acupuncture in
delaying
chemotherapyinduced nausea
and vomiting.
Tas, D., Uncu, D., Sendur,
M.A., Koca, N., & Zengin,
N. (2014). Acupuncture as a
complementary treatment for
cancer patients receiving
chemotherapy. Asian Pacific
Journal of Cancer
Prevention, 15(7), 31393144.
To determine if
acupuncture
would alleviate
side effects such
as pain, nausea,
vomiting, sleep
quality, and
anxiety that are
associated with
chemotherapy for
Design and
Measures
Randomized
crossover
study from
May 2013 to
March 2014.
Measures:
Nausea was
graded on a
scale of 0 to
10 with the
higher
number
being most
severe.
Quality of
life was also
assessed
using a
functional
assessment
tool
(Rithirangsri
roj et al.,
2014). The
vomiting
was graded
based if
vomiting
occurred.
A welldesigned
research
study
Measures:
Patients
were
assessed
using the
Sample
Outcomes /
statistics
N=70 patients The acupuncture
randomized
group
and crossed
experienced
over, 25 were higher delays in
excluded and
nausea than the
8 declined to
group being
participate;
administered
n=35
ondansetron
acupunture in (P=0.004). The
the 1st cycle of acupuncture
chemotherapy, group
n=35
encountered less
acupunture in nausea and
the 2nd cycle
vomiting in
of
delayed onset
chemotherapy, (P=0.04 and
n=35
P<0.001).
ondanestron in
the 1st cycle of
chemotherapy,
n=35
ondanestron in
the 2nd cycle
of
chemotherapy
N=45 patients
monitored for
efficiency of
acupuncture in
managing side
effects of
pain, nausea,
vomiting,
sleep quality,
and anxiety.
There was a
decrease in the
occurrence of
nausea,
vomiting,
insomnia, pain
score, and
anxiety
(p<0.001).
DECREASING NAUSEA AND VOMITING
doi:10.7314/APJCP.2014.15.
7.3139
cancer patients.
Yeh, C., Chien, L., Chiang,
Y., Lin, S., Huang, C., &
Ren, D. (2012). Reduction in
nausea and vomiting in
children undergoing cancer
chemotherapy by either
appropriate or sham auricular
acupuncture points with
standard care. The Journal of
Alternative and
Complementary Medicine,
18(40), 334-340.
doi:10.1089/acm.2011.0102
To evaluate if the
use of
acupuncture in
addition to
standard care
would reduce
nausea and
vomiting in
children during
the course of their
chemotherapy
treatments.
11
Insomnia
Severity
Index, the
Beck
Anxiety
Scale, Visual
analogue
scale, and
grading
nausea and
vomiting on
a scale of 0
to 4 (Tas et
al., 2014).
Randomized
crossover
spanned over
a total of 21
days.
N=10
pediatric
patients, 6
patients
refused, 6
were
Measures:
excluded;
Marrow
n=patients
Assessment
receiving
of Nausea
auricular
and Emetics acupressure
was
and regular
amended so standard care,
that it may
n=patients
be utilized
receiving only
for pediatrics standard care,
studies. “The n=patients
score
receiving
severity was sham auricular
recorded as
acupuncture
‘slight’,
‘moderate,’
and ‘severe’,
and the score
of
antiemetics
effect was
recorded as
‘did not
help’ and
‘provided
relief’” (Yeh
Patients were
administered
auricular
acupressure with
regular standard
care had a lower
incidence of
nausea
(p=0.0289) and
vomiting
(p=0.0024) than
patients
receiving
standard care
alone.
Participants
receiving sham
auricular
acupuncture
experience a
decreased
incidence of
nausea
(p=0.1058) and
vomiting
(p=0.0172) in
comparison to
those receiving
only standard
care There was
no significant
difference in
DECREASING NAUSEA AND VOMITING
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et al., 2012,
p. 336).
occurrence of
nausea
(p=0.2590) and
vomiting
(p=0.1775)
between that
received
auricular
acupuncture or
sham auricular
acupuncture.