Sunday, September 22, 2013

Acupuncture and Inflammatory Bowel Disease

On Pins and Needles Looking for a Cure

Acupuncture is one of the favorite “traditional Chinese medicine” techniques put forth as alternative medicine for many conditions.  It involves placing needles at strategic locations called meridians, which assist in the alignment of qi within the body.  Similar treatments include acupressure (used to put strategic pressure at meridian locations) and moxibustion (burning a particular mixture of dried mugwort, in combination with acupressure or standalone).

Acupuncture is generally tested for efficacy by using sham acupuncture – utilizing real practitioners and processes, but the needles are either not placed at “meridians” or penetrating needles aren’t used.  Unlike drug trials, there is a greater possibility in bias given the protocols.  First, individuals that are used to having acupuncture applied may question new locations or sensations.  Second, the study can’t be blinded from those providing the therapy (they know if they are performing real or sham acupuncture). This requires more stringent controls elsewhere in the study design to compensate.  Studies looking at acupuncture in IBD have been performed on at least two occasions, and other studies are currently planned.(1)  While there are two other studies published in the Journal of Traditional Chinese Medicine, a lack of adherence to acceptable research protocols and standards precludes their results from being validated.(2)

In a 2006 study looking at acupuncture as a treatment for ulcerative colitis (in conjunction with moxibustion), Joos et al treated 29 randomly assigned patients for 5 weeks (with follow-up for 16 weeks) with either real acupuncture or sham acupuncture (through non-meridian points).  The study primarily looked at the colitis activity index, finding that “the CAI decreased from 8.0 (+-/3.7) to 4.2 (+-/2.4) points and in the control group from 6.5 (+-/3.4) to 4.8 (+-/3.9) points”.  Given the initial differences in CAI starting points (likely an artifact of a small sample size), both showed equal drops in CAI.  The authors draw a conclusion that is used by many in alternative medicine and is the antithesis of evidence based medicine, specifically “Both traditional and sham acupuncture seem to offer an additional therapeutic benefit in patients with mild to moderately active UC.”  Unfortunately, all this study did was to confirm the presence of the placebo effect in acupuncture.  The same conclusion would have held for any control group exhibiting the placebo effect and is not proof of efficacy.(3)

The second study frequently cited was similarly performed by Joos et al, but focusing on Crohn’s disease.  The study looked at 51 patients over 4 weeks, with a twelve week follow-up.  The study looked at blood markers as well as the CDAI scores for an acupuncture group and a control group.  Similar to  the UC study, there was a CDAI drop in both groups, finding that in the treatment group “the CDAI decreased from 250 ± 51 to 163 ± 56 points as compared with a mean decrease from 220 ± 42 to 181 ± 46 points in the control group”.  The study further found a drop in α1-acid glycoprotein concentration in the treatment group but not the control group.  The authors concluded that “Apart from a marked placebo effect, traditional acupuncture offers an additional therapeutic benefit in patients with mild to moderately active CD.”(4)  

Although they note the placebo effect, their conclusion on the finding of an additional therapeutic benefit is way overdrawn.  The CDAI measure suffers from the same issues as in the UC study.  The alpha-1 AGP numbers appear promising, but suffer from a few problems.  First, when multiple blood measures are used, the p-value needs to be adjusted to consider any of the values having a positive outcome, not just a single measure, which was not done.  Second, alpha-1 AGP has been shown to be a poor marker for Crohn’s activity, though the research largely post-dates the author’s work (but the work is still cited as evidence of efficacy by others).(5)

A systemic review of gastrointestinal diseases and acupuncture in 2007 looked at the two studies above as well as the two poorly controlled studies from China that were noted.  The systemic review, based on the two studies above, reached an even more far-reaching set of conclusions.  Specifically:

With regard to inflammatory bowel diseases, the study results of Joos et al[20,21] show a statistically and clinically relevant improvement of disease activity pointing to some specific effects of acupuncture. Subgroup analyses in both studies revealed that higher activity grades and disease duration of less than 5 years seem to predict the efficacy of acupuncture therapy. Psychoneuroimmunologic pathways influenced by acupuncture may be an explanation for the presumed acupuncture effects in Crohn and Colitis patients. This needs to be evaluated in further clinical and experimental studies

The conclusion is baffling, until you look at the author list (a conflict of interest statement would have been nice).  Unfortunately, the data do not support the conclusions drawn.(6)

The two trials that studied the use of acupuncture to treat IBD showed nothing conclusive beyond the placebo effect.  Because acupuncture has no sound biological basis for action and there are no large scale trials showing its efficacy, there is no reason to recommend it for IBD treatment at this time.  Fortunately, if proper sterilization techniques are used, it is relatively benign, tongue in cheek references to spontaneous human combustion aside. (7)

Bottom Line

·         Acupuncture has been proposed as a treatment option for both Crohns and Ulcerative Colitis.
·         There is currently no evidence that acupuncture has efficacy in treating IBD beyond the placebo effect.
2.       Wu, Meng, Jingqing Hu, and Biaoyan Liu. "The Reporting Quality Assessment of Complex Interventions’ Articles in Traditional Chinese Medicine." Evidence-Based Complementary and Alternative Medicine 2013 (2013).
3.       Joos, Stefanie, Nicole Wildau, Ralf Kohnen, Joachim Szecsenyi, Detlef Schuppan, Stefan N. Willich, Eckhart G. Hahn, and Benno Brinkhaus. "Acupuncture and moxibustion in the treatment of ulcerative colitis: a randomized controlled study." Scandinavian journal of gastroenterology 41, no. 9 (2006): 1056-1063.
4.       Joos, Stefanie, Benno Brinkhaus, Christa Maluche, Nathalie Maupai, Ralf Kohnen, Nils Kraehmer, Eckhart G. Hahn, and Detlef Schuppan. "Acupuncture and moxibustion in the treatment of active Crohn’s disease: a randomized controlled study." Digestion 69, no. 3 (2004): 131-139.
5.       Chambers, R. E., P. Stross, R. E. Barry, and J. T. Whicher. "Serum amyloid A protein compared with Creactive protein, alpha 1antichymotrypsin and alpha 1acid glycoprotein as a monitor of inflammatory bowel disease." European journal of clinical investigation 17, no. 5 (1987): 460-467.
6.       Schneider, Antonius, Konrad Streitberger, and Stefanie Joos. "Acupuncture treatment in gastrointestinal diseases: A systematic review." World Journal of Gastroenterology 13, no. 25 (2007): 3417.

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