PEP Topic 

Rikkunshito is a traditional Japanese medicine that has been used to treat a variety of gastrointestinal (GI) disorders. Animal studies suggest it has an impact in the GI tract as a 5-HT4 receptor antagonist and appears to have some effect in increasing ghrelin concentrations. Rikkunshito has been studied for its effect on anorexia in patients with cancer.

Effectiveness Not Established

Systematic Review/Meta-Analysis

Mogami, S., & Hattori, T. (2014). Beneficial effects of Rikkunshito, a Japanese Kampo medicine, on gastrointestinal dysfunction and anorexia in combination with western drug: A systematic review. Evidence-Based Complementary and Alternative Medicine, 2014, 519035. 

doi: 10.1155/2014/519035


STUDY PURPOSE: To summarize the physiologic and clinical benefits of rikkunshito, a Japanese Kampo medicine, alone and in combination with western therapies and to summarize the drug interactions of rikkunshito
TYPE OF STUDY: Systematic review

Search Strategy:

KEYWORDS: Rikkunshito, rikkunshi-to, TJ-43, Liu-Jun-Zi-Tang
INCLUSION CRITERIA: Articles that studied the use of rikkunshito in conjunction with western medicine
EXCLUSION CRITERIA: Articles that did not use rikkunshito and were not written in English

Literature Evaluated:

TOTAL REFERENCES RETRIEVED: Eighty-two references that included two books, 14 reviews, and 66 original manuscripts, of which, 30 were human studies and 36 were animal studies. 
EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Sixty articles of the initial 82 reviewed were used. Data abstraction was used and data were presented descriptively. Sixty articles were referenced, but that information was not listed or described in the body of the article.

Sample Characteristics:

  • TOTAL PATIENTS INCLUDED IN REVIEW: Not able to determine the total number of patient is this review
  • KEY SAMPLE CHARACTERISTICS: Characteristics spanned a wide variety of diagnoses that included cancer, dyspepsia, and gastroesophageal reflux disease. 

Phase of Care and Clinical Applications:

PHASE OF CARE: Multiple phases of care
APPLICATIONS: Pediatrics, elder care, palliative care


Twelve studies looked at rikkunshito’s effects on anorexia in subjects with cancer. Three studies utilized human subjects. These studies looked at patients receiving cisplatin for unresectable/relapsed gastric cancer and gemcitabine for pancreatic cancer with ascites. The results showed that rikkunshito improved anorexia in 19 patients receiving docetaxel/5-FU/cisplatin. When evaluated for nausea, mood, and activities of daily living, scores in these metrics were significantly lower in the rikkunshito group compared to controls. In a crossover design, the effects of rikkunshito on cisplatin-induced anorexia were studied, which demonstrated an increase in oral intake, no decrease in ghrelin levels, and a lower grade of anorexia in patients taking rikkunshito compared to when those patients were not taking rikkunshito. In a retrospective study of 39 patients who were treated with gemcitabine, improvement in anorexia was noted as well as increased survival. In the studies of anorexia, models utilizing animals revealed improved food intake with increased ghrelin levels that were noted along with improved survival. Rikkunshito was combined with various western agents in these studies and was shown to improve gastrointestinal side effects/symptoms and not affect the effects of the agents (e.g., SSRIs, antimicrobial agents, antiparkinson agents). There was no indication for any effect on CYP isoenzymes or P-gp.


Rikkunshito combined with western anticancer medicines has been shown to improve appetite by increasing ghrelin levels, thereby reducing anorexia.


All studies were conducted in Japan where Kampo medicine is used frequently and is readily available for use. There were very few human studies conducted; the majority of studies utilized animal subjects.

Nursing Implications:

Rikkunshito appears to be a promising medication to improve anorexia, but there is inadequate data to recommend this agent at this time. Additional studies utilizing human subjects and a variety of anticancer medications as well as cancer diagnoses need to be conducted. In addition, studies are needed to evaluate the use of rikkunshito for the management of gastrointestinal symptoms in other diagnoses (e.g., depression, Parkinson’s, gastroesophageal reflux disease).

Research Evidence Summaries

Ohno, T., Yanai, M., Ando, H., Toyomasu, Y., Ogawa, A., Morita, H., . . . Kuwano, H. (2011). Rikkunshito, a traditional Japanese medicine, suppresses cisplatin-induced anorexia in humans. Clinical and Experimental Gastroenterology, 4, 291–296.

doi: 10.2147/CEG.S26297

Study Purpose:

To investigate the effect of Rikkunshito on ghrelin secretion and on cisplatin-induced anorexia in humans

Intervention Characteristics/Basic Study Process:

Ten patients were randomly divided into two groups. Both groups received S-1 (80 mg/m²/day orally split into twice-a-day dosing after meals) plus chemotherapy for 21 consecutive days followed by a 14-day rest period. The total daily dose of S-1 was determined based on body surface area (BSA): 80 mg (BSA < 1.25 m²), 100 mg (BSA 1.25–1.5 m²), or 120 mg (BSA > 1.5 m²). Cisplatin 60 mg/m² was administered IV on day 8. All patients were administered 16 mg of dexamethasone and 3 mg of granisetron IV one hour before cisplatin infusion and 8 mg of dexamethasone on days 9 and 10. Group A was started on Rikkunshito for the first course of chemotherapy, followed by a second course of chemotherapy without Rikkunshito. Treatment with Rikkunshito was reversed for group B. During the intervention period, patients took Rikkunshito 7.5 g (2.5 g three times per day by mouth) before each meal on days 1–21. Patients in the control period did not take anything. Blood samples to assess acylated ghrelin levels were collected before and three hours after administration of the cisplatin. Patients were hospitalized after the administration of cisplatin and monitored for five days. The amount of oral intake of each meal was observed and scored, and the average oral intake during five days was calculated.

Sample Characteristics:

  • The study reported on 10 patients (5 in each arm).
  • Mean patient age was 61.8 years, with a range of 50–72 years. (Median age was not calculated in the article.)
  • The sample was 80% male and 20% female.
  • All patients had gastric cancer: 40% had recurrent disease, 60% had unresectable disease.
  • Patients had an Eastern Cooperative Oncology Group performance status score of 0–1 and may have had up to one prior chemotherapy regimen.


  • Single site
  • Inpatient setting
  • Japanese study, suggesting it was done in Japan

Phase of Care and Clinical Applications:

  • Patients were undergoing active treatment.
  • The study has clinical applicability for late effects and survivorship.

Study Design:

A crossover design was used.

Measurement Instruments/Methods:

Anorexia, nausea, and vomiting were scored according to National Cancer Institute common toxicity criteria.


During the Rikkunshito-on period, there was no significant decrease in the plasma concentration of acylated ghrelin between before and after administration. During the Rikkunshito-off period, the average concentration of plasma-acylated ghrelin three hours after cisplatin administration decreased from preadministration levels but not statistically significantly.

The average oral intake in the Rikkunshito-on period was significantly larger than that in the Rikkunshito-off period (p = 0.0496). The grade of anorexia was significantly lower in the Rikkunshito-on period than in the Rikkunshito-off period (p = 0.0441), and the average oral intake in the Rikkunshito-on period was significantly larger than that in the Rikkunshito-off period. The grade of nausea was not significant; however, the grade in the Rikkunshito-on period tended to be lower. The difference in grade of vomiting was not significant. The time to treatment failure rates during the Rikkunshito-on period were not different. Hypertension, edema, hypokalemia, pseudohyperaldosteronism, hepatic toxicity, and transaminitis have been previously reported but did not appear to be more significant in the Rikkunshito-on or -off period for this study.


Rikkunshito might prevent anorexia induced by cisplatin, and the prophylactic administration of Rikkunshito was felt to be effective in chemotherapy with cisplatin. Patients could continue their treatment on schedule.


  • The study had a small sample size, with less than 30 participants.
  • The trial was nonrandomized; crossover design may cloud what led to benefit.
  • The authors have taken a combination herbal product and assumed that any positive effects in this study are due to ghrelin levels. Previous studies cited by the authors have had mixed results regarding the effect of ghrelin on cachexia and anorexia. The positive effects seen may not be related to effect of Rikkunshito on ghrelin at all but rather due to other effects of one of more of the herbs in Rikkunshito. The presence of multiple herbs in this product may be a confounder.

Nursing Implications:

Rikkunshito may be effective at preventing anorexia induced by cisplatin, but the small sample size makes it unlikely that this data can be generalized. Additional studies are necessary.