Ginger
Scientific Name(s): Zingiber officinale Roscoe; occasionally Z. capitatum Smith. 1 Family: Zingiberaceae
Common Name(s): Ginger , ginger root , black ginger , zingiberis rhizoma
Clinical Overview
Uses of Ginger
Ginger and its constituents have antiemetic, cardiotonic, antithrombotic, antibacterial, antioxidant, antitussive, antihepatotoxic, anti-inflammatory, antimutagenic, stimulant, diaphoretic, diuretic, spasmolytic, immunostimulant, carminative, and cholagogue actions. Ginger is used to promote gastric secretions, increase intestinal peristalsis, lower cholesterol levels, raise blood glucose, and stimulate peripheral circulation. Traditionally used to stimulate digestion, its modern uses include prophylaxis for nausea and vomiting (associated with motion sickness, hypermesis gravidarum, and anesthesia), dyspepsia, lack of appetite, anorexia, colic, bronchitis, and rheumatic complaints. Ginger can be used as a flavoring or spice as well as a fungicide and pesticide.
Ginger Dosing
Ginger root has been given for nausea in clinical trials in 1 g doses, repeated as necessary.
Contraindications
Contraindications have not yet been identified.
Pregnancy/Lactation
Generally recognized as safe or used as food. Avoid dosages above those found in food because safety and efficacy are unproven.
Ginger Interactions
Based on available reports, no special precautions are necessary in patients eating ginger and taking warfarin. However, since warfarin has a narrow therapeutic index, patients should be cautioned against use of herbal products without consulting their health care provider and to report any signs of bleeding.
Ginger Adverse Reactions
Excessive amounts may cause CNS depression and may interfere with cardiac function or anticoagulant activity.
Toxicology
There are no reports of severe toxicity in humans from the ingestion of ginger root.
Botany
A native of tropical Asia, this perennial is cultivated in tropical climates such as Australia, Brazil, China, India, Jamaica, West Africa, and parts of the US. 1 The rhizome is used medicinally and as a culinary spice. Cultivation with natural manuring is thought to increase the spiciness of the rhizome and is therefore preferred to wildcrafting. 1 The rhizome is harvested between 6 and 20 months; taste and pungency increase with maturity. 1 The plant carries a green-purple flower in terminal spikes; the flowers are similar to orchids. 1 , 2
History
Medicinal use of ginger dates back to ancient China and India; references to its use are found in Chinese pharmacopoeias, the Sesruta scriptures of Ayurvedic medicine as well as Sanskrit writings. 1 Once its culinary properties were discovered in the 13th century, use of this herb became widespread throughout Europe. In the Middle Ages, it held a firm place in apothecaries for travel sickness, nausea, hangovers, and flatulence. 1
Ginger and its constituents are stated to have antiemetic, cardiotonic, antithrombotic, antibacterial, antioxidant, antitussive, antihepatotoxic, anti-inflammatory, antimutagenic, stimulant, diaphoretic, diuretic, spasmolytic, immunostimulant, carminative, and cholagogue actions as well as to promote gastric secretions, increase intestinal peristalsis, lower cholesterol levels, raise blood glucose, and stimulate peripheral circulation. 1 , 3 , 4 Traditionally, ginger is used as an acrid bitter to strengthen and stimulate digestion. 1 Modern uses include prophylaxis for nausea and vomiting (associated with motion sickness, hyperemesis gravidarum and surgical anesthesia), dyspepsia, lack of appetite, anorexia, colic, bronchitis, and rheumatic complaints. 1 , 3 , 4 , 5 The food industry uses ginger oil as a spice and ginger extract in the manufacturing of ginger ale. 1 , 5 In China, ginger root and stem are used as pesticides against aphids and fungal spores. 6
Ginger is in the official pharmacopoeias of Austria, China, Egypt, Great Britain, India, Japan, the Netherlands, and Switzerland. 1 , 4 , 5 It is approved as a nonprescription drug in Germany and as a dietary supplement in the US. 4 Only scraped or unscraped, unbleached ginger is accepted as a medicinal-grade drug, containing greater than or equal to 1.5% volatile oil. 1 Langner et al consider Jamaican and Cochin ginger to be the best varieties, and report the Japanese plant to be of inferior quality and do not recommend it for medicinal use. 1 Standards of quality for ginger can be found in The United States Pharmacopeia National Formulary .
Powder, alcoholic solutions, and freshly pressed juice and oil are found in pharmaceutical preparations. Ginger as a spice, seasoning, flavoring, oil, extract, and oleoresin is considered “Generally Recognized As Safe” (GRAS) by the FDA. 7 , 8 Deliberate or accidental adulterants include exhausted (overprocessed) ginger, Japanese ginger, Z. cassummunar , Z. zerumbet , and other foreign substances. 1
Chemistry
It had long been believed that the “pungent principles” of ginger were also responsible for its pharmacologic activity, and this has been found to be accurate. The characteristic aroma of ginger is due mainly to the presence of zingiberol in the volatile oil. 1 , 9
The major constituents in ginger rhizomes are carbohydrates (50 to 70%), which are present as starch. The concentration of lipids is 3 to 8% and includes free fatty acids (eg, palmitic, oleic, linoleic, linolenic, capric, lauric, myristic), triglycerides, and lecithins. Oleoresin provides 4 to 7.5% of pungent substances as gingerol homologues, shogaol homologues, zingerone, and volatile oils. 1 Volatile oils are present in 1 to 3% concentrations and consist mainly of the sesquiterpenes beta-besabolene and zingiberene; other sesquiterpenes include zingiberol and zingiberenol; numerous monoterpenes are also found. Amino acids, raw fiber, ash, protein, phytosterols, vitamins (ie, nicotinic acid and vitamin A), and minerals are among the other constituents. 1 , 6
Analyses of the oleoresins have resulted in the identification of a class of structurally related cardiotonic compounds called gingerols, which upon dehydration, form shogaols and degrade further to zingerone. 1 , 6 [6]-gingerol and [6]-shogaol are the main components however, the pharmacologically active compounds [6]- and [10]-dehydrogingerdione, and [6]- and [10]-gingerdione have also been identified. 1 , 10 , 11
Ginger Uses and Pharmacology
Human clinical trials have examined ginger's antiemetic effects related to kinetosis (motion sickness), perioperative anesthesia, and hyperemesis gravidarum. However, little is still known regarding its human pharmacology in these settings. Animal studies have described enhanced GI transport as well as anti-5-hydroxytryptamine (5HT 3 ) and possible CNS antiemetic effects. 12
One clinical trial (n = 12) employed gastroduodenal manometry to evaluate prokinetic effects of ginger in fasting and postprandial healthy subjects. A significant increase in antral motility and in corpus motor response with a trend toward increased motor response in all regions was found. 13 However, no effect of ginger on gastric motility using an acetaminophen absorption technique was found in 16 healthy volunteers. 14
KinetosisIt has been proposed that, unlike antihistamines which act on the CNS, the aromatic, carminative, and possibly absorbent properties of ginger ameliorate the effects of motion sickness in the GI tract directly. 1 , 6 , 15 It may increase gastric motility and block GI reactions and subsequent nausea feedback. 15
Animal dataResearch reveals no animal data regarding the use of ginger for kinetosis.
Clinical dataOne double-blind study (n = 36) compared the effect of 940 mg powdered ginger root, 100 mg dimenhydrinate, and placebo (chickweed herb) in the prevention of motion sickness. Preparations were administered 20-25 minutes prior to placing blindfolded subjects in a rotating chair. Those receiving ginger root remained in the chair longer (average of 5.5 minutes, compared with 3.5 and 1.5 minutes for the dimenhydrinate and placebo groups, respectively), and 50% remained in the chair for the full 6 minutes of the test; none of the subjects in the other groups completed the test. In general, it took longer for the ginger group to begin feeling sick, but once the vomiting center was activated, sensations of nausea and vomiting progressed at the same rate in all groups. 15
A double-blind, placebo-controlled study in seasick marine cadets (n = 79) reported significant reductions in symptoms (vomiting and cold sweats) and noticeably suppressed dizziness following administration of 1 g ginger rhizome. Nystagmus was reported as unchanged. 1 A study involving 1741 participants on an ocean sailing tour described the administration of 250 mg ginger prior to departure to be as effective as cinnarizine, scopolamine, dimenhydrinate, meclizine, and cyclizine. 1 Ginger (500 mg every 4 hours) and dimenhydrinate (100 mg every 4 hours) were compared in another double-blind study with similar protective effects, however those receiving ginger reported no side effects. 1
Other trials have shown no significant differences among ginger, antiemetics, and placebo with regard to gastric as well as nongastric symptoms. Two separate investigations showed no effect of ginger on the CNS impairment caused by kinetosis as subjects retained the ability to perform certain head and eye movements. A scopolamine/ d -amphetamine combination proved most effective but resulted in definite side effects. 1
Another placebo-controlled study evaluated participants' ability to tolerate head movements in a rotating chair while blindfolded. 16 Ginger was compared against scopolamine (0.6 mg orally) in several small groups of test subjects. It was concluded that ginger administered as 500 to 1000 mg powdered root or 1000 mg fresh root provided no protection against motion sickness under various test conditions, while the scopolamine group was able to tolerate a significant increase in number of head movements. In this same study, gastric emptying and gastric electrical activity (via electrogastrogram [EGG]) were evaluated in 2 more small groups of subjects. Ginger partially inhibited and stabilized tachygastria but did not affect EGG amplitude. The authors concluded that symptoms of motion sickness can be dissociated from gastric electrical activity and that the partial tachygastric effects of ginger offer little to relieve the onset or severity of these symptoms. 16
Postoperative nausea and vomiting (PONV)Animal data
Research reveals no animal data regarding the use of ginger for PONV.
Clinical dataThe anti-emetic effects of ginger have been compared with metoclopramide and droperidol in prevention of PONV. 17 , 18 One prospective, randomized, double-blind trial (n = 120) evaluated 1 g powdered ginger root and 10 mg metoclopramide administered 1 hour prior to anesthesia in women undergoing gynecological laparoscopy; anesthesia was induced with propofol, fentanyl, and atracurium. Findings supported those of previous studies; ginger and metoclopramide were equally effective and were more effective than placebo in reducing the incidence of PONV (21%, 27%, and 41%, respectively). The need for postoperative antiemetics was significantly reduced in those receiving ginger over the placebo group (15% vs 38%, P = 0.006). 17
In a placebo-controlled comparison against droperidol, no statistically significant difference was found with ginger root or ginger root plus droperidol in the incidence of PONV in 120 women undergoing outpatient gynecological laparoscopy; anesthesia was induced with thiopental, fentanyl, and succinylcholine. Patients were given droperidol (1.25 mg IV), oral ginger root (1 g given 1 hour prior to induction of anesthesia and 1 g given 30 minutes prior to discharge), ginger plus droperidol or placebo. While incidences of postoperative nausea (20%, 22%, 33%, and 32%) and vomiting (13%, 25%, 25%, and 35%) did not reach statistical significance, the figures do appear to have potential clinical importance. 18
A dosage study (randomized, double-blind, placebo-controlled) concluded that 0.5 g and 1 g powdered ginger root were ineffective in reducing the incidence of PONV in 108 patients. However, study methods in this particular trial could be questioned. To allow the identifying aroma of the ginger capsules to dissipate, capsules were removed from their original container and stored in pairs for 2 days in plastic bags until the odor disappeared. It has already been noted that the pungent principles (including the sesquiterpenes lending ginger its characteristic aroma) are responsible for ginger's pharmacological activity. 19
Hyperemesis gravidarumAnimal data
Research reveals no animal data regarding the use of ginger for hyperemesis gravidarum.
Clinical dataPregnant women suffering from hyperemesis gravidarum received ginger (250 mg 4 times daily) or placebo for 4 days. About 70% of women subjectively preferred ginger treatment, with greater symptomatic relief being observed compared with placebo. 20
Selective serotonin reuptake inhibitor discontinuation syndromeAnimal data
Research reveals no animal data regarding the use of ginger for selective serotonin reuptake inhibitor discontinuation syndrome.
Clinical dataOne case report describes the successful use of ginger in one female patient with subsequent beneficial use in over 20 additional patients for the amelioration of symptoms (eg, disequilibrium, nausea) associated with abrupt discontinuation or intermittent noncompliance of selective serotonin reuptake inhibitors. Administration of 1100 mg ginger root 3 times daily at the onset of discontinuation-induced symptoms resulted in partial to complete relief of symptoms within 24 to 48 hours; ginger therapy was continued for approximately 2 weeks, the time required for symptoms to usually abate. 21
Other usesThe gingerols and the related compound shogaol have been found to possess cardiotonic activity. Crude methanol extracts of ginger were known to have a strong positive inotropic effect on animal hearts. The gingerols have been found to exert a dose-dependent positive inotropic action at doses as low as 10 -4 g/ml when applied to isolated atrial tissue. 22 Cardiac workload is further decreased by dilation of blood vessels via stimulation of prostacyclin biosynthesis. 1
Administration of [6]-gingerol and [6]-shogaol (1.75 to 3.5 mg/kg IV and 70 to 140 mg/kg orally) inhibited spontaneous motor activity, produced antipyretic and analgesic effects, and prolonged hexobarbital-induced sleeping time in laboratory animals. [6]-shogaol was generally more potent than [6]-gingerol and showed an intense antitussive effect when compared with dihydrocodeine phosphate. Interestingly, [6]-shogaol inhibited intestinal motility when given IV, but facilitated GI motility after oral administration. Both compounds were cardiodepressant at low doses and cardiotonic at higher doses. 10
[6]-gingerol, the dehydrogingerdiones, and the gingerdiones are potent inhibitors of prostaglandin biosynthesis through the inhibition of prostaglandin synthetase (cyclo-oxygenase). 11 Inhibition of thromboxane synthesis results in inhibition of platelet aggregation, but evidence indicates this is dose dependent or may only occur with fresh ginger. 1 , 13 , 23 The only 2 in vivo reports of impaired platelet function involved consumption of large quantities of raw ginger; 1 subject consumed large quantities of marmalade containing 15% ginger, and 1 study administered 5 g raw fresh ginger daily for 1 week. 23 One study was unable to detect measurable changes in bleeding time, platelet count, or platelet aggregation following a single 2 g dose of dried ginger in 8 healthy males. 23
Ginger has been reported to have weak fungicidal, strong antibacterial, and anthelmintic properties. Active constituents have been shown to inhibit reproduction of Escherichia coli , Proteus species, staphylococci, streptococci, and Salmonella but to stimulate lactobacilli growth. 1 In vitro anthelmintic activity has been documented for the volatile oil of Z. purpureum Roxb against Ascaridia galli Schrank. 5 Activity has also been reported against parasites, such as Schistosoma and Anisakis . 1
The cytotoxic compound zerumbone and its epoxide have been isolated from the rhizomes of Z. zerumbet . This plant, also a member of the family Zingiberaceae, has been used traditionally in China as an antineoplastic. The isolates inhibited the growth of a hepatoma tissue culture. 24 In addition, juice prepared from ginger root has been found to inactivate the mutagenicity of tryptophan pyrolysis products in vitro. 25
Dosage
Ginger root has been given for nausea in clinical trials in 1 g doses, repeated as necessary. 26 , 27
Pregnancy/Lactation
Documented adverse effects. 28 , 29 Avoid use.
Interactions
There is no report of an interaction occurring with administration of warfarin and ingestion of ginger. Available data are conflicting. There are studies demonstrating inhibition of platelet aggregation in individuals ingesting ginger, 30 , 31 , 32 which may increase the risk of bleeding. There is also a study showing that short term (less than 24 hours) ingestion of ginger powder capsules (2 g) had no effect of bleeding time, platelet count, or platelet aggregation. 33
Adverse Reactions
In culinary quantities, the root is generally devoid of activity. Large overdoses carry the potential for causing CNS depression. Inhibition of platelet aggregation has been reported after consumption of large (clinically impractical) amounts of ginger but returned to normal within one week of discontinuation. 13 Cardiotonic and cardiodepressant activity have been demonstrated in animals. Reports that ginger extracts may be mutagenic or antimutagenic in experimental test models require confirmation. 1 , 20
There is no convincing evidence regarding the safety of ingesting large amounts of ginger by pregnant women. The German Commission E contraindicates ginger for use in morning sickness, however, data are lacking to support toxic effects in pregnant women. 1 , 3 , 4 The FDA considers ginger as a food supplement as generally recognized as safe (GRAS). 7 , 8
Toxicology
There are no reports of severe toxicity in humans from the ingestion of ginger root.
Bibliography
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4. Blumenthal M. 1997. Popular Herbs in the US Market: Therapeutic Monographs . Austin, TX:American Botanical Council.
5. Newall C, et al. 1996. Herbal Medicines: A Guide for Healthcare Professionals . London: Pharmaceutical Press.
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7. Food and Drug Administration, Department of Health and Human Services. Code of Federal Regulations, 21CFR182.10. Accessed via http://www.access.gpo.gov/nara/cfr/cfr-table-search.html . March 2000.
8. Herb safety and drug interactions . 1998. Boulder, CO: Herb Research Foundation.
9. Tyler V. The New Honest Herbal . Philadelphia, PA: GF Stickley Co., 1987.
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11. Kiuchi F, et al. Inhibitors of prostaglandin biosynthesis from ginger. Chem Pharm Bull . 1982;30(2):754–57.
12. Lumb A. Mechanism of antiemetic effect of ginger. Anaesthesia . 1993;48(12):1118.
13. Micklefield G, et al. Effects of ginger on gastroduodenal motility. Int J Clin Pharmacol Ther . 1999;37(7):341-46.
14. Phillips S, et al. Zingiber officinale does not affect gastric emptying rate: a randomized, placebo-controlled, crossover trial. Anaesthesia . 1993;48(5):393-95.
15. Mowrey D, et al. Motion sickness, ginger, and psychophysics. Lancet . 1982;1(8273):655-57.
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17. Phillips S, et al. Zingiber officinale (ginger)-an antiemetic for day case surgery. Anaesthesia . 1993;48(8):715-7.
18. Visalyaputra S, et al. The efficacy of ginger root in the prevention of postoperative nausea and vomiting after outpatient gynaecological laparoscopy. Anaesthesia . 1998;53:506-10.
19. Arfeen Z, et al. A double-blind randomized controlled trial of ginger for the prevention of postoperative nausea and vomiting. Anaesth Intensive Care . 1995;23:449-52.
20. Fischer-Rasmussen W, et al. Ginger treatment of hyperemesis gravidarum. Eur J Obstet Gynecol Reprod Biol . 1991;38(1):19-24.
21. Schechter J. Treatment of disequilibrium and nausea in the SRI discontinuation syndrome. J Clin Psychiatry . 1998;59(8):431-32.
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23. Lumb A. Effect of dried ginger on human platelet function. Thromb Haemost . 1994;71(1):110-11.
24. Matthes H, et al. Phytochemistry . 1980;19:2643 .
25. Morita K, et al. Agric Biol Chem . 1978;42(6):1235.
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27. Grontved A, Brask T, Kambskard J, Hentzer E. Ginger root against seasickness. A controlled trial on the open sea. Acta Otolaryngol . 1988;105:45-49.
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29. Ernst E. Herbal medicinal products during pregnancy: are they safe? BJOG . 2002;109:227-235.
30. Srivastava KC. Effect of onion and ginger consumption on platelet thromboxane production in humans. Prostaglandins Leukot Essent Fatty Acids . 1989;35:183-185.
31. Dorso CR, et al. Chinese food and platelets. N Engl J Med . 1980;303:756-757.
32. Verma SK, et al. Effect of ginger on platelet aggregation in man. Indian J Med Res . 1993;98 (Section B):240-242.
33. Lumb AB. Effect of dried ginger on human platelet function. Thromb Haemost . 1994;71:110-111.
34. Babbar O. Protective patterns of different interferons: possible efficacy of chick embryo and plant interferons against microbial infections and malignancies of animals. Indian J Exp Biol . 1982;20:572-76.
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