Effects of acupuncture and moxibustion on ulcerative colitis: An overview of systematic reviews

This study represents the first comprehensive evaluation of the methodological quality of systematic reviews on acupuncture and moxibustion in the treatment of ulcerative colitis (UC). Ulcerative colitis is a chronic inflammatory bowel disease that significantly affects patients' quality of life, characterized by inflammation of the colonic mucosa, abdominal pain, bloody diarrhea, and fecal urgency. With the global increase in incidence, especially in developing countries such as China, where the annual rate has risen to 1.18 per 100,000 people, finding effective and safe treatments has become crucial. The researchers conducted a systematic search in seven databases through May 2023, identifying 356 initial records.

After a rigorous selection process, 10 studies were included in the final analysis, encompassing 109 randomized clinical trials with 8,556 participants. The studies were published between 2010 and 2023, six in Chinese and four in English. The methodology employed four internationally recognized assessment tools: AMSTAR-2 for methodological quality, PRISMA for reporting quality, ROBIS for risk of bias, and GRADE for quality of evidence. The results revealed significant problems in the overall quality of the studies.

Using AMSTAR-2, only two studies were classified as low quality, while eight received a critically low classification. No study reached high methodological quality. The main problems identified included lack of prior registration of the research protocol, incomplete search strategies, and absence of a list of excluded studies with justifications. The PRISMA evaluation showed that no study completed all checklist items, with 40% of studies presenting significant deficiencies in reporting.

Items such as search strategy, evaluation of evidence certainty, and protocol registration were consistently poorly reported. Risk of bias, assessed by ROBIS, showed that 60% of studies had high risk, mainly due to problems in the search and selection of studies. Using GRADE, the quality of evidence was concerning: of the 27 outcomes evaluated, none had high quality, only 22% had moderate quality, 30% low quality, and 48% very low quality. The main factors contributing to low quality were limitations in the design of the original studies, especially problems with randomization, allocation concealment, and blinding, present in 100% of outcomes.

Imprecision of results affected 59% of outcomes, risk of publication bias 44%, and inconsistency 26%. Despite the methodological limitations, the analysis of clinical outcomes suggests that acupuncture and moxibustion may be effective in the treatment of UC. Studies demonstrated improvement in clinical cure rates compared with conventional medications, with a favorable safety profile. Reported adverse effects were mild and self-limited, including nausea, vomiting, dizziness, and minimal bleeding, with lower incidence than in the control group.

Subgroup analysis revealed efficacy of different modalities, including intermediate moxibustion, suspended moxibustion, fulminant moxibustion, and various combinations with Western medicine. However, the heterogeneity among studies was considerable, limiting the interpretation of pooled results. The clinical implications are important but should be interpreted with caution. Although traditional Chinese medicine, particularly acupuncture and moxibustion, offers advantages such as lower hepatic and renal toxicity, economy, and convenience compared with conventional pharmacologic treatments, the current evidence does not allow for definitive recommendations due to low methodological quality.

The study identified several areas for improvement in future research: prospective protocol registration, more comprehensive search strategies including gray literature, better control of bias in original trials, and standardization of diagnostic criteria and outcomes. The need for high-quality multicenter studies with larger samples is evident to definitively establish the role of acupuncture and moxibustion in the management of ulcerative colitis.