Rédacteurs : Johan Nguyen, Claude Pernice

Inflammatory Bowel Disease

Rectocolite hémorragique & maladie de Crohn

1. Systematic Reviews and Meta-Analysis

1.1. Generic Acupuncture

1.1.1. Bae 2023 (Crohn's Disease)

Bae JH, Kang SY, You SE, Jeong HI, Jang S, Kim KH. The Effects of Acupuncture on Crohn's Disease: a systematic review and meta-analysis. J Pharmacopuncture. 2023 Sep 30;26(3):211-226. https://doi.org/10.3831/KPI.2023.26.3.211

Objectives Crohn's disease is a chronic gastrointestinal disease that belongs to inflammatory bowel disease. This systematic review aims to assess the level of evidence in randomized controlled trials (RCTs) on the effects of acupuncture for Crohn's disease.
Methods We searched 12 databases from the date of the establishment of each database up to May, 2023 for relevant RCTs. The risk of bias of each study was assessed independently by three reviewers. The level of evidence of meta-analysis was assessed using GRADE (Grading of Recommendations, Assessment, Development, and Evaluation).
Results A total of 12 studies were included. The effective rate (odds ratio [OR] 3.23, 95% confidence interval [CI] 1.43, 7.30) for mild to moderate Crohn's disease patients showed a significant difference between the acupuncture with moxibustion group and the sham-acupuncture with sham-moxibustion group. CDAI change (mean difference [MD] -74.15, 95% CI -93.28, -55.01) for mild to moderate Crohn's disease showed a significant difference between the acupuncture with moxibustion group and the sham-acupuncture with sham-moxibustion group.
Conclusion Although acupuncture with moxibustion showed significant effects compared to sham-acupuncture with sham-moxibustion, the effect of acupuncture alone is inconclusive. Moreover, only the effect of acupuncture treatment on mild to moderate Crohn's disease patients was derived as a remarkable result. To confirm the effectiveness of acupuncture treatment for Crohn's disease, studies using only acupuncture for intervention or more RCTs targeting various Crohn's disease patients according to the CDAI are required.

1.1.2. Yang 2023

Yang X, He M, Tang Q, Wang Z, Jin D, Wu X, Yang Y, Ma D, Sun M, Li T. Assessment of anti-inflammatory efficacy of acupuncture in patients with inflammatory bowel disease: A systematic review and meta-analysis. Complement Ther Med. 2023 Jun;74:102946. https://doi.org/10.1016/j.ctim.2023.102946

Background Inflammation has a significant role in the onset and progression of inflammatory bowel disease (IBD). Increasing attention has been paid to the use of acupuncture in IBD patients; however, its regulatory effects on inflammatory factors in IBD still require validation. Here, we systematically evaluated the effects of acupuncture on inflammatory factors in IBD patients.
Methods Eight electronic databases were searched for studies that met the inclusion criteria. After evaluating the quality of the studies selected by two reviewers, the meta-analysis was performed to assess the efficacy of acupuncture in IBD patients and the impact on inflammatory factors (TNF-α, IL-1, IL-8 and IL-10).
Results Four randomized controlled trials with a total of 228 patients satisfied the inclusion criteria. Acupuncture has a positive therapeutic impact on IBD (MD = 1.22, 95% CI [1.07, 1.39], P = 0.003). Moreover, it regulates the levels of TNF-α (MD =-60.58, 95% CI [-100.30, -20.89], P = 0.003), IL-8 (MD =-56.40, 95% CI [-60.02, -52.14], P < 0.00001) and IL-10 (MD =35.96, 95% CI [11.02, 60.91], P = 0.005) in IBD patients. However, the P value of meta-analysis in IL-1 great than 0.05.(MD =-27.90, 95% CI [-97.82, 42.02], P = 0.11).
Conclusion Acupuncture has a positive therapeutic impact on IBD and can effectively regulate inflammatory factors in IBD patients. TNF-α, IL-8 and IL-10 are more appropriate inflammatory indicators for clinically evaluating the anti-inflammatory response in the blood of IBD patients by acupuncture.

1.1.3. Wang 2020 ☆

Wang X, Zhao NQ, Sun YX, Bai X, Si JT, Liu JP, Liu ZL. Acupuncture for ulcerative colitis: a systematic review and meta-analysis of randomized clinical trials. BMC Complement Med Ther. 2020;20(1):309. [219774]. doi

Background Ulcerative colitis, characterized by diarrhea, bloody stools and abdominal pain, is a chronic, idiopathic inflammatory disease of the colonic mucosa. In recent years, the incidence of ulcerative colitis presents an increasing trend year by year. Acupuncture, as a potential effective treatment for ulcerative colitis, is widely used in clinical practice.
MethodsWe searched PubMed, the Cochrane Library, Chinese CBM Database, China National Knowledge Infrastructure, Chinese VIP Information, and Wanfang Database from the date of the establishment of each database up to March, 2019. We included randomized controlled clinical trials (RCT) comparing acupuncture versus conventional conventional medicine or comparing acupuncture combined with conventional medicine versus conventional medicine in participants with ulcerative colitis. Two authors screened all references, assessed the risk of bias and extracted data independently. We summarized data using risk ratios (RR) with 95% confidence intervals (CI) for binary outcomes. We performed meta-analyses using random effects model. We assessed overall quality of evidence using GRADE.
Results We included 13 RCTs (1030 participants, 515 in the acupuncture group and 515 in the control group). Only one study tested head acupuncture, and the other 12 tested body acupuncture. The treatment duration ranged from 14 to 60 days. Seven trials compared acupuncture alone versus conventional medicine, and six compared acupuncture combined with conventional medicine versus conventional medicine. Acupuncture combined with mesalazine showed better clinical effect (improved clinical symptoms, colonoscopy results and stool examination results) (RR 1.25, 95% CI 1.19 to 1.41; 232 participants; 4 trials; low quality evidence) and better colonoscopy curative effect (RR 1.33, 95% CI 1.04 to 1.71; 108 participants; 2 trials; moderate quality evidence) compared to mesalazine. Acupuncture showed better clinical effect compared to the combination of metronidazole and sulfasalazine (RR 1.21, 95%CI 1.10, 1.34; 318 participants; 3 trials; moderate quality evidence). There was no significant difference in the incidence of adverse events between groups.
Conclusions Both acupuncture alone and acupuncture combined with conventional medicine may be effective in treating ulcerative colitis compared to conventional medicine. Our findings must be interpreted with caution due to high or unclear risk of bias of the included trials.

1.1.4. Wang 2018

Wang Yuanyuan, Li Fei, Zhang Chi, Zhang Guoshan, Liu Mi, Yu Jie. [Meta-analysis on Acupuncture and Moxibustion in the Treatment of Inflammatory Bowel Disease]. Chinese Medicine Modern Distance Education of China. 2018;21:128-131. [201776].

目的 对近5年针灸治疗炎症性肠病(IBD)的临床疗效与安全性进行系统评价.方法 应用计算机检索中国期刊全文数据库、万方数据库、维普数据库、web of science数据库、MEDLINE数据库、PubMed数据库、Embase数据库、百度学术知识发现数据库、SPISCHLAR学术资源等在线数据库,收集2013年1月-2018年1月发表的关于针刺治疗IBD的临床随机对照试验(RCT)文章.由2名研究者按照Jadad质量评价标准对每个纳入试验进行偏倚风险和质量评估,使用Revman 5.3软件进行Meta分析.结果 共纳入符合条件文献11篇,合计836例患者.Meta分析结果表明:针灸组或针灸+西药组与西药对照组比较,临床症状明显好转.总有效率:OR =3.66,95%CI为[2.41,5.54] (P<0.01),漏斗图结果显示基本对称.不良反应发生率:OR =0.19,95%CI为[0.07,0.51](P<0.01),差异均具有统计学意义.结论 针灸治疗IBD的临床疗效明显优于常规西药组,并且不良反应率较西药治疗组低.
Objective To systematically evaluate the clinical efficacy and safety of acupuncture and moxibustion for inflammatory bowel disease (IBD) in the past 5 years.
MethodsThe method uses computer to search Chinese journal full-text database, Wanfang database, VIP database, web of science database, MEDLINE database, PubMed database. Online database of Embase database, Baidu academic knowledge discovery database, SPISCHLAR academic resources, etc., collected a randomized controlled trial (RCT) article on acupuncture treatment of IBD published from January to February 2018. Two researchers followed Jadad quality evaluation criteria were used to evaluate the risk and quality of each included trial. Meta-analysis was performed using Revman 5.3 software.
ResultsResults were included in 11 eligible articles, totaling 836 patients. Meta-analysis showed that: acupuncture group or acupuncture + western medicine group Compared with the western medicine control group, the clinical symptoms were significantly improved. The total effective rate: OR = 3.66, 95% CI was [2.41, 5.54] (P < 0.01), and the funnel plot showed basic symmetry. The incidence of adverse reactions: OR = 0.19, 95% CI was [0.07, 0.51] (P<0.01), the difference was statistically significant.
Conclusion The clinical efficacy of acupuncture in the treatment of IBD is significantly better than the conventional Western medicine group, and no The good response rate was lower than that of the western medicine treatment group.

1.1.5. Liu 2016 (vs salazosulfapyridine) ☆

Liu Zhao, Yang Jin-Sheng, Wu Yuan, Guo Lang-Tao, Zhang Hao-Bin, Qi Shu-Lan, Wang Ying-Ying. [Clinical efficacy differences in ulcerative colitis between acupuncture and salazosulfapyridine: A meta-analysis]. China Journal of Traditional Chinese Medicine and Pharmacy. 2016;2:472-478. [186917].

Objectives To systematically evaluate the efficacy difference in ulcerative colitis (UC) between acupuncture and salazosulfapyridine (SASP).
Methods Through the electronic retrieval from CNKI database, Wanfang database, VIP database, Pubmed, Embase and ScienceDirect, randomized controlled trial (RCT) literature regarding acupuncture and SASP in the treatment of UC from June of 2001 to June of 2015 was collected, and they were screened according to Inclusion and exclusion criteria. The included RCTs were evaluated, and RevMan 5. 2 software was used for data processing.
Results A total of 25 RCTs were included in the analysis, involving 2 166 patients. The quality evaluation of literature showed that the quality score was 24. 48 (61. 2%), of which intervention description had the highest score (8. 32, 69. 33%);All the included RCTs presented methodology problems, leading to probability of bias. Mete-analysis results showed that compared with SASP, acupuncture had better efficacy on short-term effective rate (OR=5. 23, 95%CI [3. 88, 7. 05], Z= 10. 83, P<0. 05) and long-term effective rate (OR=4. 15, 95%CI [1. 87, 9. 20], Z=3. 51, P<0. 05);The acupuncture could significantly improve the tumor necrosis factor levels (SMD=1. 78, 95%CI [0. 40, 3. 15], Z=2. 54, P<0. 05), IgG levels (SMD=2. 05, 95%CI [0. 24, 3. 86], Z=2. 22, P<0. 05) and IgA content (SMD=4. 27, 95%CI [1. 11, 7. 42], Z=2. 65, P<0. 05), but it could not reduce the content of IgM (SMD=0. 13, 95%CI [-0. 15, 0. 42], Z=0. 90, P>0. 05)
Conclusions It is believed that the efficacy of acupuncture is superior to SAPS on UC, but due to the low methodological quality of included studies, this conclusion will need to more rigorous design, large sample and multicenter RCTs to confirm.

1.1.6. Langhorst 2015 ☆

Langhorst J, Wulfert H, Lauche R, Klose P, Cramer H, Dobos GJ, Korzenik J. Systematic review of complementary and alternative medicine treatments in inflammatory bowel diseases. J Crohns Colitis. 2015;9(1):86-106. [184812].

Objectives We performed a systematic review for Complementary and Alternative Medicine [CAM] as defined by the National Institute of Health in Inflammatory Bowel Disease [IBD], ie Crohn's disease [CD] and ulcerative colitis [UC], with the exception of dietary and nutritional supplements, and manipulative therapies.
Methods A computerized search of databases [Cochrane Library, Pubmed/Medline, PsychINFO, and Scopus] through March 2014 was performed. We screened the reference sections of original studies and systematic reviews in English language for CAM in IBD, CD and UC. Randomized controlled trials [RCT] and controlled trials [CT] were referred and assessed using the Cochrane risk of bias tool.
Results A total of: 26 RCT and 3 CT for herbal medicine, eg aloe-vera gel, andrographis paniculata, artemisia absinthium, barley foodstuff, boswellia serrata, cannabis, curcumin, evening primrose oil, Myrrhinil intest®, plantago ovata, silymarin, sophora, tormentil, wheatgrass-juice and wormwood; 1 RCT for trichuris suis ovata; 7 RCT for mind/body interventions such as lifestyle modification, hypnotherapy, relaxation training and mindfulness; and 2 RCT in acupuncture; were found. Risk of bias was quite heterogeneous. Best evidence was found for herbal therapy, ie plantago ovata and curcumin in UC maintenance therapy, wormwood in CD, mind/body therapy and self-intervention in UC, and acupuncture in UC and CD.
Conclusions Complementary and alternative therapies might be effective for the treatment of inflammatory bowel diseases; however, given the low number of trials and the heterogeneous methodological quality of trials, further in-depth research is necessary.

1.1.7. Ji 2013 ☆

Ji J, Lu Y, Liu H, Feng H, Zhang F, Wu L, Cui Y, Wu H. Acupuncture and Moxibustion for Inflammatory Bowel Diseases: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Evid Based Complement Alternat Med. 2013. [166675].

Objectives Inflammatory bowel diseases (IBD) are recurrent and refractory which include ulcerative colitis (UC) and Crohn's disease (CD). Clinical researches about acupuncture and moxibustion treatments for IBD are increasing, while systematic reviews about their efficacy remains in a shortage. This study sought to evaluate the efficacy of acupuncture and moxibustion for IBD.
Methods Seven significant databases both in and abroad were searched for randomized controlled trials (RCTs) which compared acupuncture and moxibustion as the main intervention to pharmacotherapy in treating IBD. A meta-analysis was performed.
Results A total of 43 RCTs were included. Among the 43 included trials, 10 trials compared oral sulphasalazine (SASP) with acupuncture and/or moxibustion treatments. A meta-analysis of the 10 trials indicated that acupuncture and moxibustion therapy was superior to oral SASP.
Conclusions Acupuncture and moxibustion therapy demonstrates better efficacy than oral SASP in treating IBD. However, given the limitations of this systematic review and the included literature, definitive conclusions regarding the exact efficacy of acupuncture and moxibustion treatment for IBD cannot be drawn. Extant RCTs still cannot provide sufficient evidence and multicentre, double-blind RCTs with large sample sizes are needed to provide higher-quality evidence.

1.1.8. Joos 2011 ☆

Joos S. Review on efficacy and health services research studies of complementary and alternative medicine in inflammatory bowel disease. Chinese Journal of Integrative Medicine. 2011;17(6):403-409. [186957].

Objectives To assess the evidence of the use and efficacy for complementary and alternative medicine (CAM) in inflammatory bowel disease (IBD).
Methods A systematic literature search in MEDLINE was performed for randomized controlled trials (RCTs) in Crohn’s disease and ulcerative colitis. Moreover, a selective literature search for health services research studies on the use of CAM in patients with IBD was performed.
Results Health services research studies showed a high use of CAM in adult and pediatric patients with IBD worldwide. In contrast to the high use among IBD patients, there was a lack of high-quality data for many of the used CAM methods. Although most of the studies showed positive results, the methodological quality of most studies was rather low;therefore, the results had to be interpreted with caution. While there were many studies for probiotics and fish oil, RCTs for the highly used method homeopathy, for most herbal products, and for traditional Chinese medicine methods apart from acupuncture RCTs were completely lacking.
Conclusions The lack of high-quality studies might be the consequence of the problems associated with the funding of clinical trials involving CAM. However, having the high user rates in mind, high-quality studies assessing efficacy and safety of those methods are urgently needed. Furthermore, there is a need for better representation of CAM in undergraduate and postgraduate medical education.
Acupuncture For acupuncture, there are only two RCTs, one for CD and one for UC, both showing promising results warranting confirmation in larger studies.

1.1.9. Mu 2007 ☆

Mu JP, Wu HG, Zhang ZQ, Liu HR, Zhu Y, Shi Z, Wang XM. [Meta-analysis on acupuncture and moxibustion for treatment of ulcerative colitis]. Zhongguo Zhen Jiu. 2007;27(9):687-90. [167680].

Objectives To assess the effectiveness and safety of acupuncture and moxibustion for treatment of ulcerative colitis.
Methods Randomized controlled trials or clinical controlled trials of acupuncture and moxibustion for interfere of ulcerative colitis in recent 10 years were reviewed and Meta-analysis was made for the literature results.
Results Altogether 11 papers of clinical study were enrolled. Heterogeneous tests were conducted for the results of the 11 studies, as a result, chi2 = 8.55, P = 0.67. The fixed effect model was used for statistical analysis, after combination OR = 3.82, confidence interval of 95% was 2.65-5.52. The rhombus was located at the right side of the medium line. After Z test, Z = 7.14, P < 0.01, the therapeutic effect and the cured rate in the treatment group were significantly higher than those of the control group.
Conclusions The therapeutic effect of acupuncture and moxibustion on ulcerative colitis is superior to that of western medicine with safety and less adverse reactions

1.2. Specific Acupuncture Techniques

1.2.1. Acupoint application

1.2.1.1. Tong 2023

Tong Y, Yu Y, Yin S, Lin S, Chen Y, Su X. Efficacy and safety of acupoint application in the treatment of ulcerative colitis: A systematic review and meta-analysis. Medicine (Baltimore). 2023 Aug 18;102(33):e34489. https://doi.org/10.1097/MD.0000000000034489

Background The efficacy of acupoint application in the treatment of ulcerative colitis (UC) is still controversial. The purpose of this study is to systematically evaluate the clinical efficacy and safety of acupoint application in the treatment of ulcerative colitis.
Methods The databases of China National Knowledge Infrastructure (CNKI), Chinese Biology Medicine (CBM), VIP, Wanfang, Embase, PubMed, the Cochrane Library and Web of Science were searched. The time limit was from the establishment of the database to July 2022. The published randomized controlled trials of acupoint application in the treatment of UC were analyzed by meta-analysis and trial sequential analysis.
Results A total of 13 studies were included, with a total sample size of 878 cases. Compared with conventional western medicine, acupoint application can effectively improve the effective rates of clinical comprehensive (risk ratio [RR] 1.13, 95% confidence interval [CI] 1.06-1.20, P = .0003), syndrome (RR 1.13, 95% CI 1.03-1.24, P = .009), and interleukin-4 (IL-4) (mean differences 2.62, 95% CI 1.96-3.28, P < .00001) in the treatment of UC, and reduce interferon-γ (mean differences -5.38, 95% CI -6.81 to -3.94, P < .00001). The effective rates of colonoscopy (RR 0.94, 95% CI 0.84-1.05, P = .25), pathological examination (RR 1.04, 95% CI 0.90-1.20, P = .60) and rate of adverse reaction (RR 0.55, 95% CI 0.25-1.21, P = .14) were the same. Trial sequential analysis indicated that the benefits of effective rates of clinical comprehensive and syndrome, IL-4, and interferon-γ were conclusive. Harbord regression showed no publication bias (P = .98). The evaluation of evidence quality suggested that the evidence quality of effective rates of clinical comprehensive and syndrome was moderate and the evidence quality of other indicators was low or very low.
Conclusion Acupoint application is a safe and effective method for the treatment of UC, and has the prospect of clinical application.

1.2.2. Moxibustion

1.2.2.1. Lee 2010 ∅

Lee DH et al. Moxibustion for ulcerative colitis: a systematic review and meta-analysis. BMC Gastroenterol. 2010 Apr 7;10(1):36. [155352]

Objectifs Complementary and alternative medicine (CAM) is increasingly used for treatment of inflammatory bowel disease (IBD). Acupuncture-type treatments are among the most popular options. Several studies have reported that moxibustion is effective in ulcerative colitis (UC). The objective of this review was to assess the clinical evidence for or against moxibustion as a treatment for UC.
Méthodes We searched the literature using 18 databases from their inception to February 10, 2010, without language restrictions. We included randomized clinical trials (RCTs), in which human patients with UC were treated with moxibustion. Studies were included if they were placebo-controlled or controlled against a drug therapy or no treatment group. The methodological quality of all RCTs was assessed using the Cochrane risk of bias.
Résultats In total, five RCTs were included. All were of low methodological quality. They compared the effects of moxibustion with conventional drug therapy. Three tested moxibustion against sulfasalazine and two against sulfasalazine plus other drugs. A meta-analysis of five RCTs showed favorable effects of moxibustion on the response rate compared to conventional drug therapy (n = 407; risk ratio = 1.24, 95% CI = 1.11 to 1.38; P < 0.0001; heterogeneity: I2 = 16%).
Conclusions Current evidence is insufficient to show that moxibustion is an effective treatment of UC. Most of included trials had high risk of bias. More rigorous studies seem warranted.