Multiple acupuncture and moxibustion therapies for allergic rhinitis in adults: a network Meta-analysis of randomized controlled trials

This study represents the first comprehensive network meta-analysis comparing multiple acupuncture and moxibustion therapies for allergic rhinitis in adults. The researchers analyzed 56 randomized controlled trials involving 4,859 patients, comparing 12 different traditional Chinese medicine interventions against Western medicine and placebo. Allergic rhinitis affects up to 40% of the world's population and 250 million people in China, representing a significant public health problem with substantial impact on patients' quality of life and productivity. Although conventional medications such as intranasal corticosteroids and antihistamines are effective, they may cause adverse effects such as epistaxis, dry eyes, and sedation, leading many patients to seek safer alternatives in traditional Chinese medicine.

The methodology rigorously followed PRISMA-NMA guidelines, with a systematic search across eight databases through December 2023. The researchers evaluated four main outcomes: clinical efficacy rate, quality of life measured by the Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ), total nasal symptom score, and total non-nasal symptom score. The analysis used hierarchical Bayesian models for multiple comparisons, with ranking through SUCRA curves. The results revealed that combined therapies consistently outperformed individual interventions.

The combination of manual acupuncture with catgut embedding (MA + CE) emerged as the most effective, achieving 94.09% in the SUCRA ranking for clinical efficacy and 97.61% for quality of life improvement. This combination demonstrated superiority both in terms of clinical response rate and in reduction of RQLQ scores compared with Western medicine, with risk ratios of 1.41 and mean differences of -31.15 points, respectively. The combination of manual acupuncture with indirect moxibustion (MA + IM) was particularly effective for specific nasal symptoms, achieving 90.89% in the SUCRA ranking for total nasal symptom score. Subgroup analyses by treatment duration revealed interesting patterns: MA + HSM was more effective in the short term (1-4 weeks), while MA + CE maintained superiority in the medium to long term (4-24 weeks), suggesting different temporal profiles of therapeutic response.

The safety of the interventions was notably favorable, with adverse events reported as mild and transient, including small subcutaneous bleeding, mild pain, and rarely fainting during treatment. These effects were substantially smaller than those associated with Western medicine. Proposed mechanisms include modulation of the immune response through regulation of serum IgE, restoration of cellular immune response balance, reduction of eosinophilic aggregation, and regulation of inflammatory factors such as IL-4, IL-5, and neuropeptides. Acupuncture may activate the parasympathetic nervous system, reducing the inflammatory response of the nasal mucosa and improving mucosal protection.

The study has some important limitations. Most studies were conducted in China, limiting the global generalizability of the results. Many trials were classified as having moderate to low methodological quality, with only 19.64% considered low risk of bias. Significant heterogeneity existed across studies in terms of number of treatments, acupoint selection, number of points used, and treatment duration.

Additionally, the nature of the interventions made blinding of acupuncturists impossible, introducing potential performance bias. Inconsistency analysis revealed specific local problems, particularly in the comparison between HSM versus MA for clinical efficacy. Two-dimensional cluster analysis confirmed that MA + CE offers the best overall profile considering multiple outcomes, while the placebo group presented the worst results. Funnel plots suggested possible publication bias for some outcomes, although the distribution was relatively symmetrical for most analyses.

The clinical implications are significant for integrative medicine practitioners. The results suggest that combined acupuncture and moxibustion strategies may offer superior benefits compared with monotherapies for patients with moderate to severe allergic rhinitis. The specific choice of combination may depend on therapeutic goals: MA + CE for overall efficacy and quality of life, MA + IM for specific nasal symptoms, and different temporal considerations for short versus long-duration treatments. This study establishes a robust evidence base for the efficacy of combined traditional Chinese medicine therapies in allergic rhinitis, providing valuable guidance for evidence-based clinical decisions.

Future research should focus on high-quality multicenter clinical trials with more geographically diverse populations and standardized protocols to validate these findings and establish more precise treatment guidelines.