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Ginger: An Overview BRETT WHITE, MD, Keck School of Medicine, University of Southern California, Los Angeles, California

Ginger ( officinale) is one of the more commonly used supplements. Although often consumed for culinary purposes, it is taken by many patients to treat a variety of conditions. Ginger has been shown to be effective for pregnancy-induced and postoperative and vomiting. There is less evidence to support its use for or other types of nausea and vomiting. Mixed results have been found in limited studies of ginger for the treatment of arthritis symptoms. (Am Fam Physician 2007;75:1689-91. Copyright © 2007 American Academy of Family Physicians.)

inger (Zingiber officinale) is a Uses and Effectiveness member of the family of Ginger has been evaluated as a treatment for that includes and tur- various conditions, including motion sick- meric. The strong aroma of gin- ness, nausea and vomiting, and arthritis. G ger is the result of pungent ketones including , the that primarily has been motion sickness used in research studies. The consumed por- Ginger was found in one study to be supe- tion of the ginger is the , often rior to dimenhydrinate (Dramamine) and called “ginger root,” although it is not actu- placebo for symptoms of motion sickness.3 ally a root. The rhizome is the horizontal A follow-up study also found that 1 g of stem of the plant that sends out the roots. ginger was effective at reducing the subjec- Ginger is grown primarily in Asia and tive severity of seasickness in naval cadets tropical areas and, in addition to its culi- on the high seas, although the results were nary function, has been used since ancient not statistically significant.4 Ginger did not times for a variety of conditions, including reduce the number of participants reporting colds, fevers, and digestive problems, and vertigo. Other research has shown no benefit as an appetite stimulant. It is categorized of ginger for motion sickness.5,6 by the U.S. Food and Drug Administration as a food additive but has been studied as nausea and vomiting a treatment for nausea and vomiting, as Pregnancy-Induced. A review in 2005 ana- well as for arthritis (for which it has shown lyzed 33 studies to evaluate the effectiveness mixed results). of ginger in the treatment of pregnancy- induced nausea and vomiting.7 Only six Pharmacology studies, with a total of 675 participants, The exact mechanism of action of ginger met the inclusion criteria, being double- in relation to its properties is blind, randomized controlled trials (RCTs). unclear, although it appears to inhibit sero- Four of these studies showed ginger to be tonin receptors and to exert antiemetic effects superior to placebo, and two showed it to at the level of the gastrointestinal system and be comparable in effectiveness to 1 in the central nervous system. In relation to B6, which has been found to be effective in its potential anti-inflammatory properties, pregnancy-induced nausea. There were no ginger extract has been shown to inhibit the adverse effects of ginger on pregnancy out- activation of tumor necrosis factor α and comes.7 A Cochrane review also concluded cyclooxygenase-2 expression during in vitro that ginger was beneficial for nausea and studies of human synoviocytes.2 vomiting in pregnancy.8

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after dietary supplementation with 5 g of SORT: KEY RECOMMENDATIONS FOR PRACTICE ginger powder.16

Evidence other reported uses Clinical recommendation rating References Ginger has been studied extensively in animal Oral ginger is thought to be safe and is B 7, 8 and in vitro models, leading to speculation probably effective in the treatment of for its use as an antioxidant, antimicrobial, pregnancy-induced nausea and vomiting. antifungal, antineoplastic, and antihyperten- Oral ginger may be effective in the treatment B 9 of postoperative nausea and vomiting. sive agent. However, none of these potential uses have been studied in humans. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited- quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual Adverse Effects and Interactions practice, expert opinion, or case series. For information about the SORT evidence rating system, see page 1605 or http://www.aafp.org/afpsort.xml. Adverse effects after ingestion of ginger are uncommon, but they can include mild gas- trointestinal effects such as heartburn, diar- Postoperative. A 2006 meta-analysis evalu- rhea, and irritation of the mouth.12 Because ating the use of ginger for postoperative there is a possibility that ginger may affect nausea and vomiting showed that, in five fibrinolytic activity, it may be prudent for randomized trials with a total of 363 patients, patients taking such as war- ginger was more effective than placebo.9 farin (Coumadin) to exercise caution. Phy- Other. In relation to chemotherapy- sicians caring for patients who take induced nausea and vomiting, the addition and begin to use high doses of ginger should of ginger to the standard antiemetic regi- consider monitoring the INR response. men had no advantage in reducing nausea Ginger has been reported to have posi- or vomiting in the acute phase of cisplatin tive inotropic effects in animal models and (Platinol)-induced emesis.10 A systematic has also led to case reports of arrhythmia.17 review of six RCTs analyzing ginger for clin- Although there have been no reports of toxic ical nausea and vomiting found insufficient effects from ginger after human consump- data to draw firm conclusions.11 tion, more research analyzing adverse reac- tions and potential drug interactions needs arthritis to be performed. Studies evaluating the effectiveness of gin- ger in patients with have had Dosage mixed results. Whereas one study showed Ginger can be consumed as a fresh or ginger extract to have a statistically signifi- dried root and is often prepared in , cant effect on reducing symptoms of osteo- soft drinks (including ales), and breads. arthritis of the knee,12 in a separate crossover No specific dosing studies have been per- study the effect of ginger in osteoarthritis formed; however, most clinical research has was significant only in the first period of used between 250 mg and 1 g of the pow- treatment (i.e., before crossover).13 In a ret- dered root in capsular form, taken one to rospective case series involving 28 patients four times daily.7,9,11 For pregnancy-induced with rheumatoid arthritis, 18 with osteoar- nausea and vomiting, most research studies thritis, and 10 with muscular discomfort, used 250 mg four times daily.7 patients taking powdered ginger subjectively Rubbing the oil of ginger into painful described relief in pain and swelling.14 joints and inhaling the fumes in steamed water have been advocated, although these vascular conditions techniques have not been studied. Although one study has shown that ginger does not affect the International Normalized Final Comment Ratio (INR),15 another study demonstrated Given that many antiemetic medications have a significant increase in fibrinolytic activity the potential for sedation as a side effect, the

1690 American Family Physician www.aafp.org/afp Volume 75, Number 11 ◆ June 1, 2007 Ginger Table 1. Ginger: Key Points

Effectiveness Positive effect: pregnancy-induced and postoperative nausea and vomiting7-9 No consistent effect: osteoarthritis,12-14 rheumatoid arthritis,14 motion sickness3-6 Safety Adverse effects: uncommon, but may include heartburn, diarrhea, mouth irritation12; may increase risk of fibrinolysis Interactions: insufficient data on drug interactions; may be prudent to exercise caution when taken in high doses with anticoagulants such as warfarin (Coumadin) Dosage Dried powder: 250 mg to 1 g, one to four times daily 7,9,11 Cost $5 to $20 per month, depending on form and brand Bottom line Ginger is safe, and it probably is effective for pregnancy-induced and postoperative nausea and vomiting

Information from references 3 through 9 and 11 through 14.

use of ginger is a reasonable and safe alterna- 4. Grontved A, Brask T, Kambskard J, Hentzer E. Ginger tive to treat pregnancy-induced nausea and root against seasickness. A controlled trial on the open sea. Acta Otolaryngol 1988;105:45-9. vomiting. Ginger may also play an adjunctive 5. Stewart JJ, Wood MJ, Wood CD, Mims ME. Effects of role in the treatment of postoperative nausea ginger on motion sickness susceptibility and gastric and vomiting, for which it has been shown to function. Pharmacology 1991;42:111–20. be effective. Benefits of ginger for other forms 6. Wood CD, Manno JE, Wood MJ, Manno BR, Mims of nausea and vomiting have not been dem- ME. Comparison of efficacy of ginger with various antimotion sickness drugs. Clin Res Pr Drug Regul Aff onstrated in research studies. More research 1988;6:129-36. needs to be performed to clarify its role, if 7. Borrelli F, Capasso R, Aviello G, Pittler MH, Izzo AA. any, in the treatment of various forms of Effectiveness and safety of ginger in the treatment of pregnancy-induced nausea and vomiting. Obstet Gyne- arthritis. The effectiveness, safety, dosage, and col 2005;105:849-56. 3-9,11-14 cost of ginger are outlined in Table 1. 8. Jewell D, Young G. Interventions for nausea and vomit- ing in early pregnancy. Cochrane Database Syst Rev Members of various family medicine departments develop 2003;(4):CD000145. articles for “Complementary and Alternative Medicine.” This is one in a series coordinated by Sumi Sexton, MD. 9. Chaiyakunapruk N, Kitikannakorn N, Nathisuwan S, Leeprakobboon K, Leelasettagool C. The efficacy of ginger for the prevention of postoperative nausea and vomiting: a meta-analysis. Am J Obstet Gynecol The Author 2006;194:95-9. BRETT WHITE, MD, is medical director of the Family 10. Manusirivithaya S, Sripramote M, Tangjitgamol S, Medicine Center at the Keck School of Medicine of the Sheanakul C, Leelahakorn S, Thavaramara T, et al. University of Southern California (USC) in Los Angeles. He Antiemetic effect of ginger in gynecologic oncol- is also an assistant professor in the Department of Family ogy patients receiving cisplatin. Int J Gynecol Cancer Medicine at USC. Dr. White received his medical degree 2004;14:1063-9. at USC and completed his residency in family medicine at 11. Ernst E, Pittler MH. Efficacy of ginger for nausea and the Santa Monica–University of California, Los Angeles vomiting: a systematic review of randomized clinical Medical Center. trials. Br J Anaesth 2000;84:367-71. Address correspondence to Brett White, MD, Keck 12. Altman RD, Marcussen KC. Effects of a ginger extract on knee pain in patients with osteoarthritis. Arthritis School of Medicine, University of Southern California, Rheum 2001;44:2531-8. 1510 San Pablo St., Suite 104, Los Angeles, CA 90033 (e-mail: [email protected]). Reprints are not avail- 13. Bliddal H, Rosetzsky A, Schlichting P, Weidner MS, able from the author. Andersen LA, Ibfelt HH, et al. A randomized, placebo- controlled, cross-over study of ginger and Author disclosure: Nothing to disclose. in osteoarthritis. Osteoarthritis Cartilage 2000;8:9-12. 14. Srivastava KC, Mustafa T. Ginger (Zingiber officinale) REFERENCES in rheumatism and musculoskeletal disorders. Med 1. DerMarderosian A, Beutler JA. The Review of Natural Hypotheses 1992;39:342-8. Products. St. Louis, Mo.: Wolters Kluwer, 2006. 15. Jiang X, Williams KM, Liauw WS, Ammit AJ, Roufogalis 2. Frondoza CG, Sohrabi A, Polotsky A, Phan PV, Hun- BD, Duke CC, et al. Effect of and ginger on the gerford DS, Lindmark L. An in vitro screening assay pharmacokinetics and pharmacodynamics of warfarin in for inhibitors of proinflammatory mediators in herbal healthy subjects. Br J Clin Pharmacol 2005;59:425-32. extracts using human synoviocyte cultures. In Vitro Cell 16. Verma SK, Bordia A. Ginger, and fibrinolysis. Indian Dev Biol Anim 2004;40:95-101. J Med Sci 2001;55:83-6. 3. Mowrey DB, Clayson DE. Motion sickness, ginger, and 17. Langner E, Greifenberg S, Gruenwald J. Ginger: history psychophysics. Lancet 1982;1:655-7. and use. Adv Ther 1998;15:25-44.

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