Acupuncture and Moxibustion for Peripheral Neuropathic Pain: A Frequentist Network Meta-Analysis and Cost-Effectiveness Evaluation

This network meta-analysis evaluated the efficacy and cost-effectiveness of different acupuncture and moxibustion techniques for the treatment of peripheral neuropathic pain (PNP), a debilitating condition that significantly impairs patients' quality of life. The study included 16 randomized clinical trials with 1,308 participants, all conducted in China, comparing seven different acupuncture and moxibustion techniques with conventional pharmacologic treatments. Conditions treated included sciatica, cervical spondylotic radiculopathy, herpes zoster, postherpetic neuralgia, occipital neuralgia, cervical compression syndrome, and trigeminal neuralgia. The methodology used a frequentist approach to network meta-analysis, allowing direct and indirect comparisons between treatments.

The primary outcome was at least 20% pain intensity relief, assessed using scales such as the visual analogue scale. The results demonstrated that, with the exception of acupoint injection, all acupuncture and moxibustion techniques showed superiority over nonsteroidal anti-inflammatory drugs (NSAIDs). Techniques involving heat application were particularly effective: warm needling showed a 31% risk difference in improvement compared to NSAIDs, followed by fire needling at 26% and moxibustion at 24%. Standard acupuncture showed 20% improvement, while electroacupuncture and acupotomy showed 16% and 17%, respectively.

Interestingly, anticonvulsants — considered first-line treatment for neuropathic pain — did not show a significant difference compared to NSAIDs in this analysis. The cost-effectiveness analysis revealed that fire needling was the most economical treatment, with the lowest incremental cost per additional responder (634.08 RMB/week for direct costs), followed by warm needling (822.48 RMB/week). Even when considering total costs including productivity loss and transportation, fire needling remained the most cost-effective option (2,104.97 RMB/week). Quality assessment showed that only 12.5% of studies had low risk of bias, with 68.75% having some concerns and 18.75% high risk of bias.

The main issue identified was in the randomization processes. Sensitivity analysis confirmed the robustness of the network results, although some comparisons depended only on direct evidence due to the limited number of studies. Clinical implications suggest that acupuncture and moxibustion techniques, especially those that use heat, may be valuable alternatives for the management of PNP, offering not only superior efficacy compared to the conventional treatments studied but also better cost-effectiveness. This is particularly relevant given that PNP is a chronic condition requiring prolonged treatment and is associated with high socioeconomic costs.

The techniques studied have a favorable safety profile compared with pharmacologic medications, which can have significant adverse effects and abuse potential, especially in second- and third-line therapies that include opioids.