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- Ginkgo (Ginkgo biloba)
- Tinnitus
- Ringing in the Ear
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Date:
09-13-2013 | HC# 051352-480
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Re: Ginkgo Extracts Show Mixed Results for the Treatment of Primary Tinnitus and Show Promise for the Treatment of Tinnitus from Cerebral Insufficiency and Especially in Vascular Dementia
Hilton MP, Zimmermann EF, Hunt WT. Ginkgo biloba for tinnitus. Cochrane Database Syst Rev. March 2013;3:CD003852. doi: 10.1002/14651858.CD003852.pub3.
Tinnitus, also called ringing in the ears, is the perception of sound
when there is no external sound. Ringing, humming, hissing, crackling, and
other sounds can occur continuously or only intermittently. Some people
describe their tinnitus as mildly annoying, but others describe their tinnitus
as severe and debilitating. Tinnitus can be caused by many disorders of the ear
or auditory nerve, but it also occurs with no known cause. Tinnitus treatment
includes drugs, cognitive behavior therapy, masking (use of white noise
generators), and complementary medicine therapies, but treatment is not
effective for everyone. Ginkgo (Ginkgo
biloba) has been used medicinally for several thousand years. Ginkgo leaf
extracts are most commonly used to increase blood flow in circulatory disorders,
such as peripheral vascular disease and cerebral insufficiency, and to improve
memory and cognitive function in dementia. Some research suggests ginkgo may be
helpful in reducing tinnitus. The authors conducted this systematic review of
randomized, controlled trials to assess the effect of ginkgo in people with
tinnitus.
The following databases were searched through March 2012: the
Cochrane Ear, Nose, and Throat Disorder Group Trials Register; the Cochrane
Central Register of Controlled Trials; PubMed; EMBASE; AMED; CINAHL; LILACS;
KoreaMed; IndMed; PakMediNet; CAB Abstracts; Web of Science; BIOSIS Previews;
ISRCTN; ClinicalTrials.gov; ICTRP; and Google Scholar. Reference lists from
published studies and abstracts from conference proceedings were also searched
to identify additional trials. Randomized, controlled trials were included if patients
were ≥ 18 years of age and if the primary complaint was either tinnitus or another
condition in which tinnitus was measured. Trials were excluded if patients had
tinnitus associated with conductive hearing loss or blood vessel abnormalities
in the brain.
Only four trials that enrolled 1,543 patients met the criteria and
were included in the analysis. Three trials enrolled patients (n = 1,143) with
a primary complaint of tinnitus, and one trial enrolled patients (n = 400) with
a primary complaint of dementia, some of whom had tinnitus. In all four trials,
the methodological quality was rated as high and the risk of bias was rated as
low by the authors.
One trial was a double-blind, randomized, placebo-controlled trial
of patients with stable tinnitus (n = 978). Patients were given either placebo
or 150 mg of the ginkgo extract LI 1370 (Lichtwer Pharma; Berlin, Germany)
daily for 12 weeks. No significant differences were found between the ginkgo
and placebo groups for loudness, awareness, or impact of tinnitus. Several
shortcomings of this study were not discussed by the reviewers. The patients
were interviewed by mailed questionnaires; they did not see a physician nor did
they undergo otological examinations; some patients were not included in the
analysis for unclear reasons; and the sample size was too small for the type of
matched-pair analysis to have sufficient statistical power.
Another trial was a double-blind, randomized, placebo-controlled
trial of patients with tinnitus (n = 99). Patients were given either placebo or
120 mg of the ginkgo extract EGb 761® (Dr. Willmar Schwabe GmbH
& Co. KG; Karlsruhe, Germany) daily for 12 weeks. According to the original
paper, there was a statistically significant improvement in the loudness of
tinnitus in the ginkgo group compared to the placebo group. It remains unclear
why the reviewers refer to this as nonsignificant. No significant differences
were found for the patients' rating of tinnitus intensity or effectiveness of
treatment between the ginkgo and placebo groups.
The third trial was a double-blind, randomized, placebo-controlled
trial of patients with tinnitus (n = 66). Patients were given either placebo or
120 mg of ginkgo extract (source not identified) daily for 12 weeks. No
significant differences were found in the ratings of tinnitus status or its
improvement between the ginkgo and placebo groups. The purportedly high quality
of this study may be questioned, because a considerable proportion of patients
did not show up for the follow-up visit, mostly due to other illnesses, which
may well have had an influence on subjective ratings of tinnitus.
The fourth trial was a double-blind, randomized,
placebo-controlled trial of patients with mild-to-moderate Alzheimer's dementia
(n = 218) or vascular dementia (n = 182). Patients were given either placebo or
240 mg of ginkgo extract (source not identified) daily for 22 weeks. Patients self-rated
the presence and severity of tinnitus. After 22 weeks, dementia patients reported
significantly greater improvement with ginkgo than with placebo (P < 0.01). The
improvement in those with vascular dementia was twice that of those with
Alzheimer's dementia.
In all four trials, the reporting of adverse side effects was
similar for the ginkgo and placebo groups. The most common adverse side effects
reported by both groups were gastrointestinal upset, diarrhea, and headache.
The authors conclude that, "The limited evidence from the
included studies does not demonstrate that Ginkgo
biloba is effective for tinnitus when tinnitus is the primary complaint."
However, they did not take into account that different ginkgo extracts are
composed differently and are therefore different active substances that are not
necessarily comparable with respect to efficacy and safety. Therefore, a
meta-analysis across different ginkgo extracts cannot unequivocally ascertain
efficacy. Efficacy and safety should be demonstrated for each single extract
separately. Patients with dementia reported a small improvement in tinnitus
after taking ginkgo; the daily dose and duration were both almost twice as
great in that trial. The authors express the opinion that although this
improvement was statistically significant, it is unlikely to be clinically
significant, but do not give reasons for this. They noted that improvement in
tinnitus in those with cerebral insufficiency was supported by results from a
majority of studies that examined this condition but were excluded from the
review due to inadequate methodological quality. They suggest the following two
possible explanations for the improvement in people with cerebral insufficiency
and lack of improvement in people with primary tinnitus: (1) the etiology of
tinnitus is fundamentally different in people with cognitive insufficiency, possibly
from central vascular insufficiency or neural metabolic disorders, and (2)
ginkgo improves cognitive function in patients with dementia, which in turn improves
habituation to tinnitus. They suggest that subsequent studies should carefully
define patient populations and utilize validated questionnaires before, during,
and after treatment.
—Heather
S. Oliff, PhD
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