Efficacy of acupuncture-related therapies for gastroesophageal reflux-related chronic cough: a systematic review and meta-analysis

Gastroesophageal reflux disease (GERD) is a chronic condition that affects millions of people worldwide, characterized by the return of gastric contents into the esophagus. One of the lesser-recognized but clinically important manifestations of GERD is gastroesophageal reflux-related chronic cough (GERC), which represents approximately 25-40% of chronic cough cases in clinical practice. GERC presents unique diagnostic challenges, as up to 75% of patients do not have the classic symptoms of heartburn or regurgitation, hindering early and appropriate diagnosis. Conventional treatment with proton pump inhibitors (PPIs), although the gold standard for GERD, often shows limited efficacy for GERC, especially in cases involving non-acid reflux or esophageal hypersensitivity.

This therapeutic limitation has motivated growing interest in complementary and alternative therapies, particularly acupuncture, which has shown therapeutic potential through multiple mechanisms of action. Acupuncture, a central modality of traditional Chinese medicine, theoretically acts on GERC through regulation of gastrointestinal motility, modulation of vagal tone, inhibition of acid secretion, and elevation of esophageal sensory thresholds. Specific points such as Zusanli (ST-36), Neiguan (PC-6), and Zhongwan (CV-12) have been particularly studied for their ability to strengthen the lower esophageal sphincter and reduce both acid and bile reflux. This systematic review and meta-analysis represents one of the first comprehensive evaluations of the efficacy of acupuncture specifically for GERC.

Investigators conducted a systematic search of 11 international and regional databases through June 2025, identifying randomized controlled trials that evaluated acupuncture-related therapies for GERC. Methodology rigorously followed PRISMA guidelines, with a protocol pre-registered in PROSPERO. Five randomized controlled trials involving 390 participants were included in the final analysis, published between 2018 and 2020, all conducted in China. Studies evaluated acupuncture protocols mainly targeting the dorsal segment of the Governor Vessel (GV-6 to GV-12), with some including stimulation of non-acupuncture points.

Sample sizes ranged from 30 to 51 participants per group, with treatment duration between 4 and 8 weeks. Control groups received Western medications including PPIs such as pantoprazole, omeprazole, and esomeprazole, in addition to prokinetic agents such as domperidone and mosapride citrate. Meta-analysis results demonstrated consistent benefits of acupuncture across multiple clinical outcomes. For daytime cough, acupuncture showed statistically significant improvement compared with controls (mean difference = -0.41, 95% CI [-0.75, -0.07]), with moderate heterogeneity.

Similarly, nighttime cough scores were significantly improved in the acupuncture group (mean difference = -0.38, 95% CI [-0.59, -0.17]). Quality of life, measured by the Leicester Cough Questionnaire (LCQ), showed substantial improvements in the acupuncture group (mean difference = 2.29, 95% CI [1.99, 2.60]), representing a clinically significant benefit. Total effectiveness rate also significantly favored acupuncture (risk ratio = 1.13, 95% CI [1.01, 1.27]), with 85% effectiveness versus 75% in the control group. Regarding safety, no serious adverse events were reported in any of the included studies, with only minor events such as transient needle pain or local ecchymoses, which did not lead to treatment discontinuation.

Risk-of-bias assessment using the RoB 2 tool revealed methodological limitations, particularly related to blinding and allocation concealment. GRADE assessment rated the certainty of evidence as moderate to low, mainly due to study design limitations, small sample sizes, and moderate heterogeneity. The clinical implications of these findings are promising but require cautious interpretation. Acupuncture demonstrates potential as a safe complementary therapy for GERC, offering benefits both as standalone treatment and in combination with conventional medicine.

Results suggest that acupuncture may be particularly valuable for patients with suboptimal response to PPIs or those seeking integrated treatment approaches. However, several important limitations must be considered, including the relatively small number of studies, limited sample sizes, and all studies conducted in China, limiting generalizability to other populations and health care systems.