ST36 (Stomach 36) for Vomiting: Mechanism and Clinical Application
Limited Evidence for ST36 Specifically
The available clinical guidelines do not provide specific evidence or recommendations regarding the ST36 (Zusanli) acupuncture point for treating vomiting. While acupuncture is mentioned as a potential non-pharmacologic intervention in refractory cases, the guidelines do not detail specific acupoint mechanisms or efficacy 1.
What the Guidelines Actually Recommend for Acupuncture
Refractory Nausea and Vomiting Context
Acupuncture could be considered as a non-pharmacologic intervention when patients experience refractory emesis that has not responded to standard pharmacologic approaches targeting multiple receptor sites (dopaminergic, serotonergic, muscarinic, histaminic) 1.
The MASCC/ESMO guidelines position acupuncture alongside other alternative approaches like cannabinoids and olanzapine for patients who have failed conventional antiemetic therapy 1.
Electroacupuncture for Prophylaxis
Electroacupuncture may be considered for chemotherapy-induced nausea and vomiting prophylaxis if the technique is available and performed by a capable operator 1.
This recommendation is based on Level I evidence but notably was not included in all major guideline consensus statements, suggesting variable acceptance 1.
Clinical Context: When Acupuncture Appears in Guidelines
The guidelines mention acupuncture specifically in these scenarios:
After failure of standard antiemetics: When combinations of 5-HT3 receptor antagonists, NK1 receptor antagonists, dopamine antagonists, and corticosteroids have proven inadequate 1.
As part of multimodal therapy: Not as monotherapy, but potentially added to pharmacologic regimens 1.
For anticipatory nausea and vomiting: Though behavioral therapies (progressive muscle relaxation, systematic desensitization, hypnosis) are more strongly recommended than acupuncture for this indication 1.
Critical Limitations
The evidence base does not support ST36 as a first-line or standalone intervention for vomiting. The guidelines consistently prioritize:
Pharmacologic approaches first: Dopamine antagonists (metoclopramide, haloperidol, prochlorperazine), 5-HT3 antagonists (ondansetron), NK1 antagonists (aprepitant), and corticosteroids depending on the clinical context 1, 2, 3.
Treating underlying causes: Identifying and addressing bowel obstruction, medication effects, metabolic abnormalities, gastroparesis, or gastroesophageal reflux before considering adjunctive therapies 2, 3.
Evidence-based sequencing: The stepwise algorithm moves from established antiemetics to combination therapy before considering acupuncture 3.
Practical Clinical Approach
If considering acupuncture for vomiting, it should only be used:
- After optimizing standard antiemetic regimens targeting different receptor pathways 3.
- When performed by trained practitioners with appropriate technique 1.
- As an adjunct to, not replacement for, evidence-based pharmacotherapy 1.
- With clear documentation that conventional approaches have been maximized 1.
The absence of specific ST36 mechanism data in major clinical guidelines reflects the lack of high-quality evidence supporting its routine use in clinical practice for vomiting management.