Acupuncture for cancer patients suffering from hiccups: A systematic review and meta-analysis

doi:10.1016/j.ctim.2012.07.007

Complementary Therapies in Medicine

Volume 20, Issue 6, December 2012, Pages 447-455

https://doi.org/10.1016/j.ctim.2012.07.007 Get rights and content

Summary

Objective

The objective of this review was to assess the effectiveness of acupuncture for treating hiccups in patients with cancer.

Method

Thirteen databases were searched from their inception through July 2011 without language restrictions. Randomised clinical trials (RCTs) were included if acupuncture was used as the sole treatment or as a part of a combination therapy with conventional drugs for hiccups in cancer patients. Studies were included if they compared acupuncture to placebo, drug therapy or no treatment. Cochrane criteria were used to assess the risk of bias.

Results

A total of 5 RCTs met our inclusion criteria. All of the included RCTs were associated with a high risk of bias. The majority of studies suggested favourable effects of acupuncture compared with conventional treatments. A meta-analysis revealed superior response rates for acupuncture compared with intramuscular injections (n = 162; RR, 1.87; 95% CI 1.26–2.78; P = 0.002; heterogeneity: χ² = 3.16, P = 0. 21, I² = 37%).

Conclusions

This systematic review provides very limited evidence for the effectiveness of acupuncture compared with the conventional therapy (intramuscular injections) for treating hiccups. The total number, as well as was the methodological quality, of the RCTs included in this review was low. Rigorous RCTs will be necessary in the future to test the efficacy of acupuncture for treating hiccups in cancer patients.

Introduction

Hiccups are caused by involuntary, intermittent, spasmodic contractions of the diaphragm and intercostal muscles. A hiccup starts with a sudden inspiration and ends with an abrupt closure of the glottis. Although hiccups are thought to develop through the hiccup reflex arc, the exact pathophysiology of hiccups remains unclear. The aetiologies include gastrointestinal disorders, respiratory abnormalities, psychogenic factors, toxic-metabolic disorders, central nervous system dysfunctions and irritation of the vagus and phrenic nerves.¹ Most benign hiccups can be controlled by a traditional empirical therapy, such as breath holding and swallowing water. Persistent hiccups lasting longer than 48 h can interfere with daily activities and lead to insomnia, sleep disturbance, fatigue, anxiety, depression, malnutrition, dehydration, electrolyte imbalance, cardiac arrhythmia, and even death.2, 3, 4, 5

Cancer patients experience a variety of symptoms and treatment-related respiratory complications that can significantly impair their quality of life. Some of the most common complications encountered in clinical practice include cough, haemoptysis, dyspnoea, airway obstruction, aspiration syndromes, thromboembolic disease, infection, and hiccups.6, 7 The incidence of prolonged hiccups is unknown but generally considered to be low.⁸ Out of 400 patients referred for palliative care, hiccups were reported by only 2%.⁹

A wide range of pharmacological and non-pharmacological interventions has been used to treat persistent and intractable hiccups. Pharmacological approaches, including baclofen, gabapentin, chlorpromazine, haloperidol, metoclopramide, lidocaine, valproic acid and nifedipine, have not proven to be consistently effective.¹⁰ Baclofen seems to be the most commonly employed drug to treat hiccups, but it has frequent adverse effects, including sedation, insomnia, dizziness, weakness, ataxia, and confusion.11, 12 Lidocaine is used to treat incapacitating hiccups,¹³ and the only side effect of nebulised lidocaine is a short-term loss of the gag reflex.¹⁴ All drug therapies for hiccups have been reported to cause adverse reactions in terminally ill patients.¹⁵ Many diverse non-pharmacological interventions, mostly related to pharyngeal stimulation, have also been used to treat hiccups, but their effectiveness is equally uncertain.

Acupuncture has long been used to treat hiccups in China.16, 17 Acupuncture is a well-known alternative therapy practiced worldwide, but its effectiveness for treating hiccups has rarely been tested.18, 19 Currently, no systematic review specifically addressing acupuncture for the treatment of hiccups in cancer patients is available. Hence, this systematic review aims to summarise and critically evaluate the evidence from clinical trials that have tested the effectiveness of acupuncture as a treatment for hiccups in cancer patients.

Section snippets

Data sources

The following databases were searched from their inception through July 2011: Medline, AMED, EMBASE, CINAHL, PsycINFO, the Cochrane Library 2011 (Issue 5), the Korean Studies Information Service System (KISS), DBPIA, the Korean Institute of Science and Technology Information (KISTI), the Research Information Service System (RISS), KoreaMed, the Korean National Assembly Library, and the Chinese Medical Database (CNKI). The search was conducted in Korean, Chinese, and English with the following

Results

Our search strategy generated 346 hits, and 5 articles met our inclusion criteria (Fig. 1). The key data from all of the included RCTs are listed in Table 1.21, 22, 23, 24, 25 All of the included trials were from China. Four trials were published in Chinese,21, 25 and one was published in English.²⁴ Four RCTs used a two-arm parallel group design,21, 22, 23, 25 and one adopted a three-arm parallel group design.²⁴ The treatments in all of the RCTs were based on the principles of traditional

Discussion

Few rigorous RCTs testing the effects of acupuncture for hiccups in cancer patients are currently available, and the existing studies provide limited evidence of the superiority of acupuncture over conventional therapies for patients with cancer-related hiccups. Our meta-analysis of three trials demonstrated that acupuncture may be superior to drug injections in treating hiccups in cancer patients. Whether the findings of the beneficial effects of acupuncture compared with conventional drug

Conclusion

This systemic review provides very limited evidence for the effectiveness of acupuncture in the management of hiccups in cancer patients. The total number of RCTs included in the analysis was low, and the risk of bias in these RCTs was high. Further investigations seem warranted but should first overcome the methodological shortcomings of the existing evidence.

Conflict of interest

The authors declare that they have no competing interests.

Author's contribution

T.Y.C. and M.S.L. designed the review, performed searches, appraised and selected trials, abstracted data, contacted authors for additional data, carried out analysis and interpretation of the data, and drafted this report. E.E. helped with the study design and critically reviewed the manuscript. All authors read and approved the final version of the manuscript.

Acknowledgement

T.Y.C. and M.S.L. were supported by Korea Institute of Oriental Medicine (C12080 and K11111).

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Cited by (18)

Persistent hiccups following thalamic hemorrhage: A case report
2023, Heliyon
Persistent hiccups (lasting more than 48 hours) can cause physical and emotional distress. They can result in dehydration, exhaustion, malnutrition, insomnia, wound dehiscence, ventilatory desynchronization, and hemodynamic changes. Hiccups are thought to be due to a complex reflex arc involving peripheral nerves and central structures such as the brainstem, temporal lobe, basal ganglia, hypothalamus, and spinal cord levels C3-5. Medullary strokes, for instance, have been reported to cause hiccups. We report a patient with a thalamic bleed who developed persistent hiccups. A 56-year-old man was brought to the hospital in an unresponsive state. He was intubated for airway protection. CT brain showed a left thalamic hemorrhage with edema and mass effect on the 3rd ventricle, intraventricular extension of hemorrhage, and hydrocephalus. An external ventricular drain was placed successfully with adequate drainage. One week after admission, the patient developed persistent abdominal jerks. These jerks were occurring every 3–4 seconds and would last for hours with brief periods of remission. He was started on levetiracetam 1000 mg IV bid and then increased to 1500 mg IV BID without any improvement of symptoms. The patient was also placed on EEG which did not reveal any epileptiform abnormality but did show an EMG artifact. His electrolytes including sodium, and potassium, and corrected calcium levels were normal. He did not have any evidence of pneumonia or other infections. It was determined that these jerks were likely hiccups. Metoclopramide 10 mg IV was tried without any benefit. He was then started on Baclofen 10 mg PO TID which resulted in a significant improvement in hiccups. Our case suggests that thalamic lesions might also lead to persistent hiccups.
Acupuncture for cancer-related conditions: An overview of systematic reviews
2022, Phytomedicine
Acupuncture is commonly used for cancer-related conditions worldwide, and evidence is increasing year on year. There is a need to summarize the evidence of acupuncture for cancer-related conditions comprehensively and critically.
To evaluate and summarize the systematic reviews (SRs) that assess the effects and safety of acupuncture for cancer-related conditions, and to inform clinical practice and future studies.
A comprehensive search was conducted on Pubmed, Embase, the Cochrane Library, Web of Science, CNKI, VIP, Sinomed, and Wanfang from their inception to October 16, 2021. SRs of randomized controlled trials (RCTs) on acupuncture for cancer-related conditions were to be included. Two reviewers screened the eligible articles, and four reviewers in pair extracted data and assessed the methodological quality/risk of bias of all included reviews by AMSTAR 2 and ROBIS tools. The overlap of primary studies was measured by calculating corrected covered areas. Data from the included reviews were synthesized with a summary of meta-analysis or narrative description.
Fifty-one SRs of RCTs on acupuncture for cancer-related conditions were included and synthesized. The methodological quality of SRs included 1 “high”, 5 “low” and 45 “very low” by AMSTAR 2. Sixteen SRs assessed as low risk of bias (31.37%), and 35 SRs had high risk of bias (68.63%) by ROBIS. Acupuncture showed effective on systemic conditions in relation to different cancers, including cancer-related pain (17 SRs, 80 RCTs), fatigue (7 SRs, 18 RCTs), insomnia (4 SRs, 10 RCTs), quality of life (2 SRs, 15 RCTs); conditions in relation to chemo-radiotherapy, including nausea and vomiting (3 SRs, 36 RCTs) and bone marrow suppression (2 SRs, 21 RCTs); and conditions in relation to specific cancers, including breast cancer-related menopause (3 SRs, 6 RCTs), hot flashes (12 SRs, 13 RCTs), arthralgia (5 SRs, 10 RCTs), and nasopharyngeal cancer-related dysphagia (1 SRs, 7 RCTs). Acupuncture appeared to have benefit for patients with lymphoedema (3 SRs, 3 RCTs), gastrointestinal function (5 SRs, 27 RCTs), and xerostomia (4 SRs, 7 RCTs). Limited evidence showed inconsistent results on acupuncture for chemotherapy-induced peripheral neuropathy (3 SRs, 6 RCTs), depression and anxiety (3 SRs, 9 RCTs). Acupuncture was regarded as a safe therapy for cancer patients as no severe adverse events related were reported.
Evidence from SRs showed that acupuncture is beneficial to cancer survivors with cancer-related pain, fatigue, insomnia, improved quality of life, nausea and vomiting, bone marrow suppression, menopausal symptoms, arthralgia, and dysphagia, and may also be potential for lymphoedema, gastrointestinal function, and xerostomia. For neuropathy, depression and anxiety, acupuncture should be used as an option based on individual conditions. Acupuncture is relatively safe without serious adverse events. More well-designed clinical trials of acupuncture are recommended on cancer-related depression and anxiety, arthralgia, xerostomia, gastrointestinal dysfunction and dysphagia.
Hiccups in Cancer Patients Receiving Chemotherapy: A Cross-Sectional Study
2021, Journal of Pain and Symptom Management
Citation Excerpt :
Among treatment choices for hiccups, physical maneuvers, pharmacological treatment, complementary and alternative medicine, and surgery were determined.3 When nonpharmacological methods are examined, moderate hiccups can be controlled with traditional empirical therapy such as holding one's breath and swallowing water.36 When our study is examined, it was determined that methods such as blowing into a pipe, drinking lemon juice, breath-holding exercises, drinking water and eating food were used.
Hiccups are a symptom in cancer patients but it's less researched.
The aimed to determine of prevalence of hiccups and treatment approach used in hiccup management in cancer patients receiving chemotherapy for nursing care.
This study used a descriptive cross‐sectional design with self‐reported questionnaires and was conducted from November 2018–May 2019 in Turkey. For collection of the data, a Patient Information Form (sociodemographic and disease characteristics), and a Hiccups Evaluation Form were used for the patients.
Hiccups were observed in 37 (23%) of the 160 patients who met the criteria for inclusion in the study. The great majority of the patients suffering from hiccups were male (65.9%) and the type of cancer in the majority of these patients was gastrointestinal cancer (54.1%). It was determined that the duration of hiccups in 83.8% of patients observed with hiccups was between 0 and 48 hours, that the average severity of their hiccups was 3.81 ± 2.25 (0–10), and that hiccups in 59.5% of these patients was of low severity. It was found that only 10.8% of patients suffering from hiccups used pharmacological methods for relief and that 27% used nonpharmacological methods.
The results of the study showed that over one-fifth of cancer patients suffered from hiccups. This situation reveals that hiccups are an important symptom that needs to be carefully emphasised in oncology practice.
Management of orphan symptoms: ESMO Clinical Practice Guidelines for diagnosis and treatment †
2020, ESMO Open
Citation Excerpt :
Acupuncture is a well-known alternative therapy practised worldwide, but its effectiveness for treating hiccups has rarely been tested. Few rigorous RCTs evaluating the effects of acupuncture for hiccups in patients with cancer are actually available, and these studies provide limited evidence of the superiority of acupuncture over conventional therapies for cancer-related hiccups (IV, D).100 Dexamethasone, one of the key medications for the prevention of ChT-induced nausea and vomiting (CINV), may cause hiccups as an AE.
Acupuncture for cancer patients undergoing radiotherapy: Protocol for a programme of research
2018, European Journal of Integrative Medicine
Citation Excerpt :
Cancers are a major public health problem and a leading cause of morbidity and mortality worldwide [1,2]. Previous research suggests acupuncture may be effective for various symptoms of cancer and the side-effects associated with its treatment [7–16]. However, previous research has largely evaluated acupuncture under ideal trial conditions, as opposed to within routine clinical settings.
Cancer patients experience a range of symptoms associated with their cancer and its treatment. Research suggests that acupuncture delivered under trial conditions may be an effective intervention for some such problems. This paper reports a protocol for a research programme to assess the feasibility of implementing and evaluating acupuncture embedded in the radiotherapy service of an academic medical centre.
The aims of the study are to examine the feasibility of acupuncture being delivered within the radiotherapy department by specially trained therapy radiographers when patients attend for treatment. The programme will culminate in a feasibility randomised controlled trial: Acupuncture for cancer patients undergoing Radiotherapy Treatment (ART).
The programme will use multiple methods: a systematic review and quality evaluation of the literature; expert consensus on model validity of the acupuncture intervention; implementation of a customised training course in acupuncture for therapy radiographers. The programme will culminate in a feasibility randomised clinical trial.
ART will investigate aspects of the feasibility of a possible definitive clinical trial of acupuncture. Aspects to be investigated include processes, resources, interventions, procedures, model validity and safety of the acupuncture intervention, and quantitative and qualitative patient outcomes, in the UCLH radiotherapy department.
100 cancer patients will be recruited to the clinical trial. Quantitative outcomes include the EORTC QLQ-C30, Multidimensional Fatigue Inventory, Memorial Symptom Assessment Scale, and EQ-5D-5L. Qualitative telephone interviews will be conducted with patients and stakeholders until data saturation.
Effects of Acupuncture, Tuina, Tai Chi, Qigong, and Traditional Chinese Medicine Five-Element Music Therapy on Symptom Management and Quality of Life for Cancer Patients: A Meta-Analysis
2016, Journal of Pain and Symptom Management
Citation Excerpt :
Tuina relieved gastrointestinal discomfort, TCM-FEMT lowered depression level, and Tai Chi improved the vital capacity of breast cancer patients. In our meta-analysis, the effect size of acupuncture on pain, fatigue, and hiccups are consistent with the reports of previous meta-analyses.27,101 A somewhat lower effect (d = 0.76) on clinical efficacy measured by KPS score was reported in an earlier meta-analysis; however, this meta-analysis only included trials on acupuncture in lung cancer.102
Most cancer patients suffer from both the disease itself and symptoms induced by conventional treatment. Available literature on the clinical effects on cancer patients of acupuncture, Tuina, Tai Chi, Qigong, and Traditional Chinese Medicine Five-Element Music Therapy (TCM-FEMT) reports controversial results.
The primary objective of this meta-analysis was to evaluate the effect of acupuncture, Tuina, Tai Chi, Qigong, and TCM-FEMT on various symptoms and quality of life (QOL) in patients with cancer; risk of bias for the selected trials also was assessed.
Studies were identified by searching electronic databases (MEDLINE via both PubMed and Ovid, Cochrane Central, China National Knowledge Infrastructure, Chinese Scientific Journal Database, China Biology Medicine, and Wanfang Database). All randomized controlled trials (RCTs) using acupuncture, Tuina, Tai Chi, Qigong, or TCM-FEMT published before October 2, 2014, were selected, regardless of whether the article was published in Chinese or English.
We identified 67 RCTs (5465 patients) that met our inclusion criteria to perform this meta-analysis. Analysis results showed that a significant combined effect was observed for QOL change in patients with terminal cancer in favor of acupuncture and Tuina (Cohen's d: 0.21–4.55, P < 0.05), whereas Tai Chi and Qigong had no effect on QOL of breast cancer survivors (P > 0.05). The meta-analysis also demonstrated that acupuncture produced small-to-large effects on adverse symptoms including pain, fatigue, sleep disturbance, and some gastrointestinal discomfort; however, no significant effect was found on the frequency of hot flashes (Cohen's d = −0.02; 95% CI = −1.49 to 1.45; P = 0.97; I² = 36%) and mood distress (P > 0.05). Tuina relieved gastrointestinal discomfort. TCM-FEMT lowered depression level. Tai Chi improved vital capacity of breast cancer patients. High risk of bias was present in 74.63% of the selected RCTs. Major sources of risk of bias were lack of blinding, allocation concealment, and incomplete outcome data.
Taken together, although there are some clear limitations regarding the body of research reviewed in this study, a tentative conclusion can be reached that acupuncture, Tuina, Tai Chi, Qigong, or TCM-FEMT represent beneficial adjunctive therapies. Future study reporting in this field should be improved regarding both method and content of interventions and research methods.

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Acupuncture for cancer patients suffering from hiccups: A systematic review and meta-analysis

Summary

Objective

Method

Results

Conclusions

Introduction

Section snippets

Data sources

Results

Discussion

Conclusion

Conflict of interest

Author's contribution

Acknowledgement

Journal of Pain and Symptom Management

Journal of Pain and Symptom Management

Chest

Controlled Clinical Trials

Hiccups

Southern Medical Journal

Disseminated metastatic tumor at dorsal surface of medulla oblongata presenting intractable hiccups. A case report

Clinical Neurology

Hiccups: causes and cures

Journal of Clinical Gastroenterology

The management of hiccups in terminally ill patients

Nursing Times

Respiratory problems in advanced cancer

Supportive Care in Cancer

Diagnosis and management of hiccups in the patient with advanced cancer

Journal of Supportive Oncology

Dysphagia, dyspepsia and hiccup

Symptoms of 400 patients referred to palliative care services: prevalence and patterns

Palliative Medicine

Hiccups: when the diaphragm attacks

Journal of Palliative Medicine

Treatment of intractable hiccup with baclofen: results of a double-blind randomized, controlled, cross-over study

American Journal of Gastroenterology

Lidocaine for severe hiccups

New England Journal of Medicine

Hiccups and other gastrointestinal symptoms

Acupuncture and cupping for treatment of hiccup in cases of cerebrovascular accident

Journal of Traditional Chinese Medicine