Rédacteurs : Olivier Goret, Johan Nguyen, Claude Pernice

Sommaire

Irritable Bowel Syndrome

Syndrome du colon irritable : évaluation de l'acupuncture

Articles connexes: - traitement par acupuncture - Acupuncture expérimentale -

1. Systematic Reviews and Meta-Analysis

☆☆☆ Evidence for effectiveness and a specific effect of acupuncture
☆☆ Evidence for effectiveness of acupuncture
☆ Limited evidence for effectiveness of acupuncture
Ø No evidence or insufficient evidence

1.1. Generic Acupuncture

1.1.1. Gan 2022 (in addition to usual care) ☆☆

Gan Y, Huang SL, Luo MQ, Chen M, Zheng H. Acupuncture in addition to usual care for patients with irritable bowel syndrome: a component network meta-analysis. Acupunct Med. 2022 Oct;40(5):403-414. https://doi.org/10.1177/09645284221085280

ObjectiveThe efficacy of acupuncture alone in the treatment of irritable bowel syndrome (IBS) is controversial, but the benefit of acupuncture added to usual care has rarely been studied. We aimed to examine the benefit of acupuncture added to usual care through network meta-analysis (NMA).
MethodsPubMed, Embase, and the Cochrane Register of Controlled Trials (CENTRAL) were searched from their inception to 1 July 2021, without any language restriction. Randomized controlled trials (RCTs) testing the effect of acupuncture alone or acupuncture combined with usual care for IBS were included. The primary outcome was improvement of global IBS symptoms. Standard NMA was performed to compare differential combinations of acupuncture (including manual acupuncture (MA) and electroacupuncture (EA)), and component network meta-analysis (CNMA) was subsequently performed to determine whether acupuncture provided additional benefits to usual care. The effect size of an intervention was measured using relative ratio (RR).
ResultsWe included 25 RCTs (n = 3041 participants) after screening 582 retrieved articles. Five RCTs were classified as low risk of bias. The results of standard NMA showed that MA combined with usual care ranked the most effective (sham acupuncture as common comparator; RR = 1.96 (95% confidence interval (CI) 1.23 to 3.12)). The results of CNMA showed that MA was the most effective component (RR = 1.38 (95% CI, 1.12 to 1.70)) when added to usual care.
ConclusionAcupuncture provided additional benefits to usual care, and it might be considered as adjunctive therapy for patients who respond inadequately to usual care.

1.1.2. Shi 2022 (vs. antispasmodics) ☆☆

Shi YZ, Tao QF, Qin D, Chen M, Yu SG, Zheng H. Acupuncture vs. antispasmodics in the treatment of irritable bowel syndrome: An adjusted indirect treatment comparison meta-analysis. Front Physiol. 2022 Oct 6;13:1001978. https://doi.org/10.3389/fphys.2022.1001978.

BackgroundAcupuncture has been extensively applied to manage irritable bowel syndrome (IBS) in clinical practice in China. Some randomized controlled trials (RCTs) have demonstrated their efficacy, but it has rarely been compared with first-line antispasmodics to verify their effectiveness. Therefore, we compare acupuncture with antispasmodics in the treatment of IBS by using an adjusted indirect treatment comparison meta-analysis.
Methods Embase, OVID Medline, and the Cochrane Central Register of Controlled Trials databases were searched from inception to 14 March 2022, with no language restrictions. RCTs comparing antispasmodics or acupuncture with placebo or one of the antispasmodics were enrolled. The primary outcome of interest was the improvement of abdominal pain. And the secondary outcomes of interest were the relief of global IBS symptoms and adverse events. The random-effects model was utilized to pool data. The effect size was measured by standardized mean difference (SMD) or relative ratio, and the effectiveness of acupuncture and different antispasmodics were ranked by P-scores.
ResultsThirty-five RCTs (n = 5,190) were included. The analysis showed that cimetropium, drotaverine, acupuncture, and pinarverium were superior over placebo in relieving abdominal pain; cimetropium (SMD, -3.00 [95%CI, -4.47 to -1.53], P-score = 0.99) ranked the most effective. In pairwise comparisons, acupuncture had a greater improvement than most antispasmodics except cimetropium and drotaverine in relieving abdominal pain, although the between-group difference was statistically insignificant. In the analysis of continuous outcome in the relief of global IBS symptoms, the result showed that pinaverium was more effective (SMD, 1.72 [95%CI, 0.53 to 2.92], P-score = 0.90) than placebo. Trimebutine and acupuncture had greater improvements than placebo, but no significant difference was shown between groups. In pairwise comparisons, acupuncture was more effective than pinaverium (SMD, -1.11 [95%CI, -1.94 to -0.28]) in relieving global IBS symptoms. In the analysis of adverse events, acupuncture had a lower adverse event rate than most of the other antispasmodics.
ConclusionCimetropium, drotaverine, and acupuncture were all better than placebo in improving abdominal pain. Acupuncture was preferred over pinaverium in relieving global IBS symptoms, and acupuncture had lower adverse events than most antispasmodics.

1.1.3. Wei 2022

Wei X, Wen Y, Wei Y, Liang X, Ma X, Zhang B, Tang X. External therapy of traditional Chinese medicine for treating irritable bowel syndrome with diarrhea: A systematic review and meta-analysis. Front Med (Lausanne). 2022 Aug 9;9:940328. https://doi.org/10.3389/fmed.2022.940328

Background Irritable bowel syndrome with diarrhea (IBS-D) is a chronic functional gastrointestinal disorder that has a significant impact on quality of life, work productivity, and healthcare resources. External therapy of traditional Chinese medicine (TCM) has positive effects on IBS-D and is simple, convenient, and low-cost. This study aimed to systematically evaluate the efficacy and safety of external therapy of TCM for IBS-D.
Methods This study was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI), Chinese Scientific Journals (VIP), Wan Fang, and Chinese Biomedical (CBM) databases were electronically searched to collect randomized controlled trials comparing external therapy of TCM with Western medicine for IBS-D from inception to 31 December 2021. Two authors independently screened, extracted, and assessed the selected studies. The Jadad scale and Cochrane Collaboration Risk of Bias tool were used to evaluate study quality. The certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE). The meta-analysis was performed using the Review Manager software (version 5.3).
Results Twenty-one studies involving 1,862 subjects were included. Acupuncture and moxibustion were the most commonly used external therapies. The meta-analysis showed that based on total effective rate with moderate certainty of evidence (n = 21 studies, n = 1,862 participants, RR = 1.25, 95% CI [1.2, 1.31], I2 = 0%, P < 0.00001), clinical cure rate with low certainty of evidence (n = 17 studies, n = 1,502 participants, RR = 1.66, 95% CI [1.4, 1.96], I2 = 1%, P < 0.00001), recurrence rate with very low certainty of evidence (n = 5 studies, n = 260 participants, RR = 0.44, 95% CI [0.34, 0.58], I2 = 0%, P < 0.00001), total symptom score (MD = -4.9, 95% CI [-7.34, -2.47]), and IBS severity scoring system score (IBS-SSS) with moderate certainty of evidence (MD = -52.72, 95% CI [-63.9, -41.53]), the experimental group had significant advantages compared with the control group. The sensitivity analysis further confirmed the robustness of the primary outcomes. The improvement in quality of life associated with IBS (IBS-QOL) was superior in the experimental group compared to the control group, and the difference was statistically significant; however, the clinical heterogeneity was strong. The inverted funnel plot of the included studies indicated a potential publication bias.
Conclusion External therapy of TCM for IBS-D alleviated abdominal symptoms, improved clinical effectiveness, and reduced recurrence with great safety. However, because of the limitations of publication bias in trials, more rigorous studies with a clinical design are necessary for further verification of the outcomes.

1.1.4. Yang 2022

Yang Y, Rao K, Zhan K, Shen M, Zheng H, Qin S, Wu H, Bian Z, Huang S. Clinical evidence of acupuncture and moxibustion for irritable bowel syndrome: A systematic review and meta-analysis of randomized controlled trials. Front Public Health. 2022 Nov 24;10:1022145. https://doi.org/10.3389/fpubh.2022.1022145

BackgroundAcupuncture and moxibustion have been widely used in the treatment of Irritable Bowel Syndrome (IBS). But the evidence that acupuncture and moxibustion for IBS reduction of symptom severity and abdominal pain, and improvement of quality of life is scarce.
MethodsPubMed, Embase, Cochrane Library, Web of Science, Chinese National Knowledge Infrastructure (CNKI), Chinese Scientific Journals Database (VIP), Wanfang Database, China Biomedical Literature Service System (SinoMed), and unpublished sources were searched from inception until June 30, 2022. The quality of RCTs was assessed with the Cochrane Collaboration risk of bias tool. The strength of the evidence was evaluated with the Grading of Recommendations Assessment, Development and Evaluation system (GRADE). Trial sequential analysis (TSA) was conducted to determine whether the participants in the included trials had reached optimal information size and whether the cumulative data was adequately powered to evaluate outcomes.
ResultsA total of 31 RCTs were included. Acupuncture helped reduce the severity of symptoms more than pharmaceutical drugs (MD, -35.45; 95% CI, -48.21 to -22.68; I 2 = 71%). TSA showed the cumulative Z score crossed O'Brien-Fleming alpha-spending significance boundaries. Acupuncture wasn't associated with symptom severity reduction (SMD, 0.03, 95% CI, -0.25 to 0.31, I 2 = 46%), but exhibited therapeutic benefits on abdominal pain (SMD, -0.24; 95% CI, -0.48 to -0.01; I 2 = 8%) compared to sham acupuncture. Moxibustion show therapeutic benefits compared to sham moxibustion on symptom severity (SMD, -3.46, 95% CI, -5.66 to -1.27, I 2 = 95%) and abdominal pain (SMD, -2.74, 95% CI, -4.81 to -0.67, I 2 = 96%). Acupuncture (SMD, -0.46; 95% CI, -0.68 to -0.24; I 2 = 47%) and the combination of acupuncture and moxibustion (SMD, -2.00; 95% CI, -3.04 to -0.96; I 2 = 90%) showed more benefit for abdominal pain compared to pharmacological medications as well as shams. Acupuncture (MD, 4.56; 95% CI, 1.46-7.67; I 2 = 79%) and moxibustion (MD, 6.97; 95% CI, 5.78-8.16; I 2 = 21%) were more likely to improve quality of life than pharmaceutical drugs.
ConclusionAcupuncture and/or moxibustion are beneficial for symptom severity, abdominal pain and quality of life in IBS. However, in sham control trials, acupuncture hasn't exhibited robust and stable evidence, and moxibustion's results show great heterogeneity. Hence, more rigorous sham control trials of acupuncture or moxibustion are necessary.

1.1.5. Amsallem 2021 ☆

Amsallem F, Sanchez S, Armoiry X, Mion F. Effectiveness of Non-Pharmacological Interventions for Irritable Bowel Syndrome: A Systematic Review. Evid Based Complement Alternat Med. 2021 Nov 8;2021:4404185. https://doi.org/10.1155/2021/4404185

Introduction Given the complexity of the therapeutic management of irritable bowel syndrome (IBS), alternative non-pharmacological therapies are frequently offered to patients. The aim of this study was to conduct a systematic review in order to establish the current evidence base for non-pharmacological interventions (body-directed and mind-body therapies) in the management of IBS.
Materials and Methods The literature was searched in several electronic databases (PubMed (including Medline), Web of Science (Clarivate Analytics), Scopus (Elsevier), ScienceDirect (Elsevier), Cochrane Library (Wiley), and Wiley Online Library (Wiley)) for randomized controlled trials (RCTs) published in the English language from 1990 to 2020. Effectiveness outcomes were examined through the change in overall IBS symptoms or abdominal pain up to 12 months after treatment.
Results 11 studies (parallel-group RCTs) were identified that enrolled 1590 participants in total. Body-directed therapies (acupuncture and osteopathic medicine) showed a beneficial effect compared with standard medical treatment for overall IBS symptoms at 6 months follow-up, while no study found any difference between body-directed and sham therapies for abdominal pain or overall IBS symptoms. It was not possible to conclude whether hypnotherapy was superior to standard medical treatment or supportive therapy for overall IBS symptoms or abdominal pain due to discordant results.
Conclusions Although body-directed therapies such as acupuncture and osteopathic medicine may be beneficial for overall IBS symptoms, higher-quality RCTs are needed to establish the clinical benefit of non-pharmacological interventions for IBS. An important challenge will be the definition of the optimal control groups to be used in non-pharmacological trials.

1.1.6. Wang 2021 ☆

Wang XY, Wang H, Guan YY, Cai RL, Shen GM. Acupuncture for functional gastrointestinal disorders: A systematic review and meta-analysis. J Gastroenterol Hepatol. 2021 Nov;36(11):3015-3026. https://doi.org/10.1111/jgh.15645

Objectives The therapeutic effect of acupuncture treatments (AT) on functional gastrointestinal disorders (FGIDs) is contentious. A meta-analysis was conducted to assess the efficacy and safety of acupuncture for FGIDs.
MethodsThe Cochrane Library, EMBASE, PUBMED, Web of Science, Wanfang Database, China National Knowledge Infrastructure, and VIP Database were searched through December 31, 2019 with no language restrictions. Risk ratio (RR) with 95% confidence interval (CI) was calculated to determine the improvement in symptom severity after treatment.
ResultsA total of 61 randomized controlled trials (RCTs) on FGIDs were included. The pooled results illustrated the following: compared to pharmacotherapy (RR 1.13, 95% CI 1.09-1.17), placebo acupuncture (RR 1.69, 95% CI 1.37-2.08), no specific treatment (RR 1.86, 95% CI 1.31-2.62), and AT as an adjuvant intervention to other active treatments (RR 1.25, 95% CI 1.21-1.30), AT had more favorable improvements in symptom severity; sub-group analysis results classified according to functional dyspepsia (n=13), irritable bowel syndrome (n=19), and functional constipation (n=8) also supported this finding; and the incidence of adverse events was lower in AT than in other treatments (RR 0.75, 95% CI 0.56-0.99).
Conclusions This meta-analysis found that AT was significantly associated with relief of FGIDs symptoms; however, the evidence level was moderate or low. Further data from rigorously designed and well powered RCTs are needed to verify the effectiveness and safety of AT as a FGIDs treatment.

1.1.7. Billing 2020 ☆

Billings W, Mathur K, Craven HJ, Xu H, Shin A. Potential Benefit with Complementary and Alternative Medicine in Irritable Bowel Syndrome: A Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol. 2020;3565(20):31296-9. [212417]. doi

Background and aims Patients with irritable bowel syndrome (IBS) may pursue complementary and alternative medicine (CAM). We conducted a comprehensive systematic review and meta-analysis examining efficacy of CAM vs. placebo or sham in adults with IBS.
Methods Publication databases were searched for randomized controlled trials of CAM therapies (herbal therapy, dietary supplements, mind-body based, body-based, and energy-healing) in adults with IBS. Data were extracted to obtain pooled estimates of mean improvement in abdominal pain (standardized mean difference [SMD]) and relative risk (RR) of overall response using random effects models. Sensitivity and subgroup analyses along with quality assessments were completed.
Results Among 2825 articles identified, 66 were included. Herbal therapy (SMD=0.47, 95% CI: 0.20 to 0.75, I2=82%) demonstrated significant benefit over placebo for abdominal pain (low confidence in estimates). Benefit with mind-body based therapy for abdominal pain was of borderline significance (SMD=0.29, 95% CI: -0.01 to 0.59, I2=78%). Herbal therapy (RR=1.57, 95% CI: 1.31 to 1.88, I2=77%), dietary supplements (RR=1.95, 95% CI: 1.02 to 3.73, I2=75%), and mind-body based therapy (RR=1.67, 95% CI: 1.13 to 2.49, I2=63%) showed benefit for overall response compared to placebo (low confidence in estimates). Body-based and energy healing therapies [acupuncture included 4RCTs] demonstrated no significant benefit over placebo or sham for abdominal pain or overall response.
Conclusion CAM therapies such as herbal or dietary supplements and mind-body based approaches may be beneficial for abdominal pain and overall response in IBS. However, overall quality of evidence is low. Rigorous, high quality clinical trials are warranted to investigate CAM in IBS.

1.1.8. Dai 2020 ☆☆

Dai YK, Wu YB, Li RL, Chen WJ, Tang CZ, Lu LM, Hu L. Efficacy and safety of non-pharmacological interventions for irritable bowel syndrome in adults. World J Gastroenterol. 2020;26(41):6488-6509. [215636]. doi

BackgroundAlthough nonpharmacological interventions (NPI) for irritable bowel syndrome (IBS) have been applied clinically, their relative efficacy and safety are poorly understood. Aim: To compare and rank different NPI in the treatment of IBS.
MethodsFive electronic databases were searched from their inception to January 12, 2020. Data of included publications were analyzed using network meta-analysis (NMA). Quality of endpoints were assessed by tools of the Cochrane Handbook and the GRADEpro software. Pooled relative risk or standardized mean difference with their corresponding 95% confidence intervals were used for statistical analysis. Surface under the cumulative ranking curve (SUCRA) probability value was conducted to rank the examined interventions. Sensitivity analysis was performed to verify the robustness of results and test the source of heterogeneity.
ResultsForty randomized controlled trials with 4196 participants were included in this NMA. Compared with routine pharmacotherapies and placebo, acupuncture and cognitive behavioral therapy (CBT) had better efficacy in relieving IBS symptoms. Based on the SUCRA values, acupuncture ranked first in improving overall clinical efficacy and avoiding adverse effects. CBT ranked first in lowering the scores of IBS symptom severity scale, self-rating anxiety scale and self-rating depression scale.
ConclusionThis study confirmed the efficacy and safety of NPI for improving IBS symptoms, which to some extent recommended several interventions for clinical practice.

1.1.9. Zheng 2019

Zheng H, Chen R, Zhao X, Li G, Liang Y, Zhang H, Chi Z. Comparison between the Effects of Acupuncture Relative to Other Controls on Irritable Bowel Syndrome: A Meta-Analysis. Pain Res Manag. 2019. [203243].

BackgroundIrritable bowel syndrome (IBS) is a functional gastrointestinal disorder with recurrent abdominal pain and altered defecation habits. We here attempted to determine the effect of acupuncture on IBS.
MethodsRandomized controlled trials (RCTs) published in CNKI, VIP, Wanfang, PubMed, Cochrane Library, EMBASE, Web of science, and ClinicalTrials.gov till July 17, 2019 were searched. Outcomes were total efficacy rates, overall IBS symptom scores, or global quality of life scores. Standardized mean difference (SMD) with 95% confidence intervals (CI) and risk ratio (RR) with 95% CI were calculated for meta-analysis.
Results We included 41 RCTs involving 3440 participants for analysis. 8 RCTs compared acupuncture with sham acupuncture, among which 3 trials confirmed the biological effects of acupuncture, especially in treating abdominal pain, discomfort, and stool frequency. No significant difference was found when acupuncture was compared with sham acupuncture, in terms of effects on IBS symptoms and quality of life (SMD = 0.18, 95% CI -0.26∼0.63, P=0.42; SMD = -0.10, 95% CI -0.31∼0.11, P=0.35), but the pooled efficacy rate data showed a better outcome for true acupuncture (RR = 1.22, 95% CI 1.01∼1.47, P=0.04), which was not supported by sensitivity analysis. Acupuncture was more effective relative to western medicine in alleviating IBS symptoms (RR = 1.17, 95% CI 1.12∼1.23, I 2 = 0%, P < 0.00001), whose effect might last 3 months. Besides, acupuncture as an adjunct to western medicine, Chinese medications, or tuina was superior over the single latter treatment (RR = 1.68, 95% CI 1.18 to 2.40, P=0.004; 1.19, 1.03 to 1.36, P=0.02; 1.36, 1.08 to 1.72, P=0.009, respectively), with high heterogeneities.
ConclusionsRelative to sham controls, acupuncture showed no superiority for treating IBS, while the advantage over western medicine was significant. Acupuncture could be used as an adjunct in clinical settings to improve efficacy. Future high-quality and large-sample-size studies with adequate quantity-effect design need to be conducted.

1.1.10. Fu 2018

Fu Chengwei, Jiang Wei. [The Effect of Acupuncture Therapy on Irritable Bowel Syndrome: a meta-analysis]. Asia-Pacific Traditional Medicine. 2018;12:101-105. [201742].

Objective To systematically compare the effect of acupuncture with pinaverium on irritable bowel syndrome.
MethodsGet together clinical randomized controlled trials of acupuncture therapy for IBS. Database of China Biology Medicine(CBM),China National Knowledge Infrastructure(CNKI),VIP Database, Wanfang data library, and English database PubMed, Cochrane Library, Web of Science. Randomized controlled clinical trials of acupuncture therapy or give priority to acupuncture therapy in the treatment of IBS, bias risk and quality assessment for each inclusion test was conducted by two researchers in accordance with the JADAD score and the Cochrane Handbook 5.1.0 standard, Meta-analysis was performed with Rev.Man 5.3 software.
ResultsEleven studies involving 1685 patients were enrolled, of whom 864 were treated with acupuncture therapy, and 821 patients were treated with pinaverium alone. The result of meta-analysis shows that acupuncture combined with moxibustion was superior to conventional western medicine in the effective RR=1.20,95%CI[1.15～1.25]>1.
ConclusionAcupuncture therapy is superior to conventional pinaverium in the treatment of IBS.

1.1.11. Chao 2014 ☆☆

Chao GQ, Zhang S. Effectiveness of acupuncture to treat irritable bowel syndrome: a meta-analysis. World J Gastroenterol. 2014;20(7):1871-7. [170907]. IF: 2.369

Aim To evaluate the efficacy of acupuncture for treatment of irritable bowel syndrome (IBS) through meta-analysis of randomized controlled trials.
Methods We searched MEDLIINE, PubMed, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials from 1966 to February 2013 for double-blind, placebo-controlled trials investigating the efficacy of acupuncture in the management of IBS. Studies were screened for inclusion based on randomization, controls, and measurable outcomes reported. We used the modified Jadad score for assessing the quality of the articles. STATA 11.0 and Revman 5.0 were used for meta-analysis. Publication bias was assessed by Begg's and Egger's tests.
Results Six randomized, placebo-controlled clinical trials met the criteria and were included in the meta-analysis. The modified Jadad score of the articles was > 3, and five articles were of high quality. We analyzed the heterogeneity and found that these studies did not cause heterogeneity in our meta-analysis. Begg's test showed P = 0.707 and Egger's test showed P = 0.334. There was no publication bias in our meta-analysis (Begg's test, P = 0.707; Egger's test, P = 0.334). From the forest plot, the diamond was on the right side of the vertical line and did not intersect with the line. The pooled relative risk for clinical improvement with acupuncture was 1.75 (95%CI: 1.24-2.46, P = 0.001). Using the two different systems of STATA 11.0 and Revman 5.0, we confirmed the significant efficacy of acupuncture for treating IBS.
Conclusion Acupuncture exhibits clinically and statistically significant control of IBS symptoms.

1.1.12. Pei 2012 ☆☆

Pei LX, Zhang XC, Sun JH, Geng H, Wu XL. [Meta analysis of acupuncture-moxibustion in treatment of irritable bowel syndrome]. Chinese Acupuncture and Moxibustion. 2012;32(10):957-60.[162036]

Purpose To evaluate the clinical efficacy and safety of acupuncture-moxibuation in treatment of irritable howel syndrome systematically
Methods Clinical randomized controlled trials on treatment of irritable bowel syndrome with acupuncture；moxibustion were collected. Through retrieval of CNKI（1979 一December of 2011 ) and VIP (1979一December of 2011), randomized and quasi-randomized controlled clinical trials on treatment of irritable bowel syndrome with control study between acupuncture and sham acupuncture or western medication were included. The test bias risk and quality assessment of each experiment were carried out by two researchers in accordance with the Cochrane Handbook 5.1.0 standard. And RevMan 5.1.6 software was adopted for the Meta analysis.
Results Eleven researches were included with totally 969 patients. Meta analysis shows that the effective rate of the combined methods of acupuncture and moxibustion [RR=1. 27,95% CI(1. 09,1. 49)]is superior to conventional western medication treatment.
Conclusion Acupuncture-moxibustion for irritable bowel syndrome is better than the conventional western medication treatment.

1.1.13. Manheimer 2012 ☆☆

Manheimer E, Wieland LS, Cheng K, Li SM, Shen X, Berman BM, Lao L.. Acupuncture for Irritable Bowel Syndrome: Systematic Review and Meta-Analysis. AM J Gastroenterol. 2012; 107(6):835-47. [160301].

Objectives Evidence-based treatment guidelines have been unable to provide evidence-based guidance on the effects of acupuncture for irritable bowel syndrome (IBS) because the only previous systematic review included only small, heterogeneous, and methodologically unsound trials. We conducted a new systematic review and meta-analysis of randomized controlled trials (RCTs) to estimate the effects of acupuncture for treating IBS.
Methods MEDLINE, the Cochrane Central Register of Controlled Trials, EMBASE, Cumulative Index to Nursing and Allied Health, and the Chinese databases Sino-Med, CNKI, and VIP were searched through November 2011. Eligible RCTs compared acupuncture with sham acupuncture, other active treatments, or no (specific) treatment, and evaluated acupuncture as an adjuvant to another treatment. Our outcomes were overall IBS symptom severity and health-related quality of life. Dichotomous data were pooled to provide a relative risk (RR) of substantial improvement after treatment, and continuous data were pooled to provide a standardized mean difference (SMD) in post-treatment scores between groups.
Results A total of 17 RCTs (N=1,806) were included. We found no evidence of an improvement with acupuncture relative to sham acupuncture on symptom severity (SMD=-0.11, 95% confidence interval (95% CI): -0.35 to 0.13; 4 RCTs) or quality of life (SMD=-0.03, 95% CI: -0.27 to 0.22; 3 RCTs). Because of the homogeneity of the results of the sham-controlled trials, results were unaffected by restriction to the four sham-controlled RCTs that used adequate randomization, blinding, and had few withdrawals/dropouts. Among RCTs that did not use a placebo control, acupuncture was more effective than pharmacological therapy (RR of symptom improvement=1.28, 95% CI: 1.12 to 1.45; 5 RCTs) and no (specific) treatment (RR = 2.11, 95% CI: 1.18 to 3.79; 2 RCTs). There was no difference between acupuncture and Bifidobacterium (RR=1.07, 95% CI: 0.90 to 1.27; 2 RCTs) or between acupuncture and psychotherapy (RR=1.05, 95% CI: 0.87 to 1.26; 1 RCT). Acupuncture as an adjuvant to another Chinese medicine treatment was statistically significantly better than the other treatment alone, in trials with a high risk of bias (RR=1.17, 95% CI: 1.02 to 1.33; 4 RCTs).
Conclusions Sham-controlled RCTs have found no benefits of acupuncture relative to a credible sham acupuncture control on IBS symptom severity or IBS-related quality of life. In comparative effectiveness Chinese trials, patients reported greater benefits from acupuncture than from pharmacological therapies. Future trials may help clarify whether or not these reportedly greater benefits of acupuncture relative to pharmacological therapies are due entirely to patients' preferences for acupuncture or patients' greater expectations of improvement on acupuncture relative to drugs.

1.1.14. Manheimer 2012 ☆☆

Manheimer E, Cheng K, Wieland LS, Min LS, Shen X, Berman BM, Lao L.. Acupuncture for treatment of irritable bowel syndrome. Cochrane Database Syst Rev. 2012;5:CD005111. doi: 10.1002/14651858.CD005111.pub3.[160292]. IF: 6.032.

Purpose The primary objectives were to assess the efficacy and safety of acupuncture for treating IBS.
Methods MEDLINE, the Cochrane Central Register of Controlled Trials, EMBASE, the Cumulative Index to Nursing and Allied Health, and the Chinese databases Sino-Med, CNKI, and VIP were searched through November 2011. Randomized controlled trials (RCTs) that compared acupuncture with sham acupuncture, other active treatments, or no (specific) treatment, and RCTs that evaluated acupuncture as an adjuvant to another treatment, in adults with IBS were included. Two authors independently assessed the risk of bias and extracted data.We extracted data for the outcomes overall IBS symptom severity and health-related quality of life. For dichotomous data (e.g. the IBS Adequate Relief Question), we calculated a pooled relative risk (RR) and 95% confidence interval (CI) for substantial improvement in symptom severity after treatment. For continuous data (e.g. the IBS Severity Scoring System), we calculated the standardized mean difference (SMD) and 95% CI in post-treatment scores between groups.
Results Seventeen RCTs (1806 participants) were included. Five RCTs compared acupuncture versus sham acupuncture. The risk of bias in these studies was low.We found no evidence of an improvement with acupuncture relative to sham (placebo) acupuncture for symptom severity (SMD-0.11, 95%CI -0.35 to 0.13; 4 RCTs; 281 patients) or quality of life (SMD = -0.03, 95%CI -0.27 to 0.22; 3 RCTs; 253 patients). Sensitivity analyses based on study quality did not change the results. A GRADE analysis indicated that the overall quality of the evidence for the primary outcomes in the sham controlled trials was moderate due to sparse data. The risk of bias in the four Chinese language comparative effectiveness trials that compared acupuncture with drug treatment was high due to lack of blinding. The risk of bias in the other studies that did not use a sham control was high due to lack of blinding or inadequate methods used for randomization and allocation concealment or both. Acupuncture was significantly more effective than pharmacological therapy and no specific treatment. Eighty-four per cent of patients in the acupuncture group had improvement in symptom severity compared to 63% of patients in the pharmacological treatment group (RR 1.28, 95% CI 1.12 to 1.45; 5 studies, 449 patients). A GRADE analysis indicated that the overall quality of the evidence for this outcome was low due to a high risk of bias (no blinding) and sparse data. Sixty-three per cent of patients in the acupuncture group had improvement in symptom severity compared to 34% of patients in the no specific therapy group (RR 2.11, 95% CI 1.18 to 3.79; 2 studies, 181 patients). There was no statistically significant difference between acupuncture and Bifidobacterium (RR 1.07, 95% CI 0.90 to 1.27; 2 studies; 181 patients) or between acupuncture and psychotherapy (RR 1.05, 95% CI 0.87 to 1.26; 1 study; 100 patients). Acupuncture as an adjuvant to another Chinese médicine treatment was significantly better than the other treatment alone. Ninety-three per cent of patients in the adjuvant acupuncture group improved compared to 79% of patients who received Chinese medicine alone (RR 1.17, 95% CI 1.02 to 1.33; 4 studies; 466 patients). There was one adverse event (i.e. acupuncture syncope) associated with acupuncture in the 9 trials that reported this outcome, although relatively small sample sizes limit the usefulness of these safety data.
Conclusion Sham-controlled RCTs have found no benefits of acupuncture relative to a credible sham acupuncture control for IBS symptom severity or IBS-related quality of life. In comparative effectiveness Chinese trials, patients reported greater benefits from acupuncture than from two antispasmodic drugs (pinaverium bromide and trimebutine maleate), both of which have been shown to provide a modest benefit for IBS. Future trials may help clarify whether or not these reportedly greater benefits of acupuncture relative to pharmacological therapies are due entirely to patients’ preferences for acupuncture or greater expectations of improvement on acupuncture relative to drug therapy.

1.1.15. Zhao 2010 ☆☆

Zhao Chen, Mu Jing-Ping, Cui Yun-Hua, Yang Ling, Ma Xiao-Peng, Qi Li. [Meta-analysis on acupuncture and moxibustion for irritable bowel syndrome]. Chinese Archives of Traditional Chinese Medicine. 2010;5:961-963. [186931].

Objectives To summarize the effectiveness of acupuncture and moxibustion as a therapy for Irritable Bowel Syndrome (IBS).
Methods RCTs were included, in which trials of acupuncture and moxibustion as a therapy for IBS in recent 10 years were extracted by computer and manual searching, for Meta-analyse. The methodological quality was assessed in accordance with the principles of EBM.
Results The fixed effect model was to be used and the tests for heterogeneity shows that there were no significant differences (χ2=9. 32, P=0. 41, P>0. 05 ), which means the effectsizes of the trials were homogeneous. We combined and estimated two groups’ effectsizes, RR=1. 28, (95% CI-1. 20 to 1. 38). Z test showed that the therapeutic effect of two groups were have significant differences (Z= 7. 143, P<0. 00001), and the rhombus was located at the right side of the medium line.
Conclusions The therapeutic effect of acupuncture and moxibustion on Irritable Bowel Syndrome is superior to that of western medicine.

1.1.16. Shen 2009 Ø

Shen YH, Nahas R. Complementary and Alternative Medicine for Treatment of Irritable Bowel Syndrome. Can Fam Physician. 2009;55(2):143-8. [153146].

Objectives To review the evidence supporting selected complementary and alternative medicine approaches used in the treatment of irritable bowel syndrome (IBS).
Methods QUALITY OF EVIDENCE: MEDLINE (from January 1966), EMBASE (from January 1980), and the Cochrane Database of Systematic Reviews were searched until March 2008, combining the terms irritable bowel syndrome or irritable colon with complementary therapies, alternative medicine, acupuncture, fiber, peppermint oil, herbal, traditional, yoga, massage, meditation, mind, relaxation, probiotic, hypnotherapy, psychotherapy, cognitive therapy, or behavior therapy. Results were screened to include only clinical trials, systematic reviews, and meta-analyses. Level I evidence was available for most interventions.
Results Soluble fibre improves constipation and global IBS symptoms. Peppermint oil alleviates IBS symptoms, including abdominal pain. Probiotic trials show overall benefit for IBS but there is little evidence supporting the use of any specific strain. Hypnotherapy and cognitive-behavioural therapy are also effective therapeutic options for appropriate patients. Certain herbal formulas are supported by limited evidence, but safety is a potential concern. All interventions are supported by systematic reviews or meta-analyses.
Conclusions Several complementary and alternative therapies can be recommended as part of an evidence-based approach to the treatment of IBS; these might provide patients with satisfactory relief and improve the therapeutic alliance.
Acupuncture Acupuncture might be beneficial for some patients with IBS, but current evidence does not support its use.

1.1.17. Lim 2006 ☆

Lim B, Manheimer E, Lao L, Ziea E,Wisniewski J, Liu J, Berman B. Acupuncture for treatment of irritable bowel syndrome. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD005111. DOI: 10.1002/14651858.CD005111.pub2.[141480]

Purpose The objective of this systematic review is to determine whether acupuncture is more effective than no treatment, more effective than ’sham’ (placebo) acupuncture, and as effective as other interventions used to treat irritable bowel syndrome. Adverse events associated with acupuncture were also assessed.
Methods The following electronic bibliographic databases were searched irrespective of language, date of publication, and publication status:MEDLINE, the Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library, EMBASE, the Chinese Biomedical Database, the Cumulative Index to Nursing and Allied Health (CINAHL), and the Allied and Complementary Médicine Database (AMED). References in relevant reviews and RCTs were screened by hand. The last date for searching for studies was 7 February 2006. Published reports of randomized controlled trials (RCTs) and quasi-randomised trials of acupuncture therapy for IBS. All eligible records identified were dually evaluated for eligibility and dually abstracted. Methodological quality was assessed using the Jadad scale and the Linde Internal Validity Scale. Data from individual trials were combined formeta-analysis when the interventions were sufficiently similar.Heterogeneity was assessed using the I squared statistic.
Results Six trials were included. The proportion of responders, as assessed by either the global symptomscore or the patient-determined treatment success rate, did not show a significant difference between the acupuncture and the sham acupuncture group with a pooled relative risk of 1.28 (95% CI 0.83 to 1.98;n=109). Acupuncture treatment was also not significantly more effective than sham acupuncture for overall general well-being, individual symptoms (e.g., abdominal pain, defecation difficulties, diarrhea, and bloating), the number of improved patients assessed by blinded clinician, or the EuroQol score. For two of the studies without a sham control, acupuncture was more effective than control treatment for the improvement of symptoms: acupuncture versus herbal medication with a RR of 1.14(95% CI 1.00 to 1.31;n=132);acupuncture plus psychotherapy versus psychotherapy alone with a RR of 1.20 (95% CI 1.03 to 1.39;n=100). When the effect of ear acupuncture treatment was compared to an unclearly specified combination of one or more of the drugs diazepam, perphenazine or domperidone, the difference was not statistically significant with a RR of 1.49(95% CI 0.94 to 2.34;n=48).
Conclusion Most of the trials included in this review were of poor quality and were heterogeneous in terms of interventions, controls, and outcomes measured. With the exception of one outcome in common between two trials, data were not combined. Therefore, it is still inconclusive whether acupuncture is more effective than sham acupuncture or other interventions for treating IBS.

1.1.18. Hussain 2006 Ø

Hussain Z, Quigley EM. Systematic Review: Complementary and Alternative Medicine in the Irritable Bowel Syndrome. Aliment Pharmacol Ther. 2006;23(4):465-71. [141341].

Objectives Complementary and alternative medical therapies and practices are widely employed in the treatment of the irritable bowel syndrome. AIM: To review the usage of complementary and alternative medicine in the irritable bowel syndrome, and to assess critically the basis and evidence for its use.
Methods A systematic review of complementary and alternative medical therapies and practices in the irritable bowel syndrome was performed based on literature obtained through a Medline search.
Results A wide variety of complementary and alternative medical practices and therapies are commonly employed by irritable bowel syndrome patients both in conjunction with and in lieu of conventional therapies. As many of these therapies have not been subjected to controlled clinical trials, some, at least, of their efficacy may reflect the high-placebo response rate that is characteristic of irritable bowel syndrome. Of those that have been subjected to clinical trials most have involved small poor quality studies. There is, however, evidence to support efficacy for hypnotherapy, some forms of herbal therapy and certain probiotics in irritable bowel syndrome.
Conclusions Doctors caring for irritable bowel syndrome patients need to recognize the near ubiquity of complementary and alternative medical use among this population and the basis for its use. All complementary and alternative medicine is not the same and some, such as hypnotherapy, forms of herbal therapy, specific diets and probiotics, may well have efficacy in irritable bowel syndrome. Above all, we need more science and more controlled studies; the absence of truly randomized placebo-controlled trials for many of these therapies has limited meaningful progress in this area.
Acupuncture No benefit over sham (1 RCT)

1.2. Special Acupuncture Techniques

1.2.1. Moxibustion

1.2.1.1. Dai 2022

Dai YQ, Weng H, Wang Q, Guo XJ, Wu Q, Zhou L, Huang L. Moxibustion for diarrhea-predominant irritable bowel syndrome: A systematic review and meta-analysis of randomized controlled trials. Complement Ther Clin Pract. 2022 Feb;46:101532. https://doi.org/10.1016/j.ctcp.2021.101532

Purpose Diarrhea-predominant irritable bowel syndrome (IBS-D) is a common functional gastrointestinal disorder that imposes heavy burden on individuals and society. Asan external therapy of traditional Chinese medicine (TCM), moxibustion is usually used to treat IBS-D. This study aimed to explore the efficacy of moxibustion in treating patients with IBS-D.
MethodsA systematic search for randomized controlled trials (RCTs) that reported the use of moxibustion in IBS-D treatment was performed in eight databases.
ResultsEleven RCTs including 725 participants meet the inclusion criteria. Compared with other positive treatments (Western medicine, TCM prescription, and acupuncture), moxibustion treatment had superior effects against IBS-D according to the meta-analysis.
ConclusionThis systematic review provided preliminary research evidence that moxibustion is effective in treating IBS-D. Rigorously designed and large-scale RCTs are required to provide more robust evidence in this area.
1.2.1.2. Tang 2016 ☆

Tang B, Zhang J, Yang Z, Lu Y, Xu Q, Chen X, Lin J. Moxibustion for Diarrhea-Predominant Irritable Bowel Syndrome: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Evid Based Complement Alternat Med. 2016. [186285].

Background The complementary and alternative medicines in treatment of diarrhea-predominant irritable bowel syndrome (IBS-D) are controversial.
Methods We searched PubMed, Ovid Embase, Web of Science, Cochrane Library databases, CNKI, Wanfang Database, CBM, VIP, and AMED for randomized controlled trials (RCTs) of moxibustion compared with pharmacological medications in patients with IBS-D. A meta-analysis was performed using both fixed and random-effects models based on heterogeneity across studies.
Results In total, 568 patients in 7 randomized controlled trials were randomly treated with moxibustion and pharmacological medications. The improvement of global IBS-D symptoms and overall scores was significant (P = 0.0001 and P < 0.0001, resp.) in patients treated by moxibustion only compared to pharmacological medications. The specific IBS-D symptoms of abdominal pain, abdominal distension, abnormal stool, and defecation frequency were alleviated in patients treated by moxibustion compared to pharmacological medications, but no significance was found except for abdominal distension and defecation frequency (P = 0.03 and P = 0.02, resp.). There were no serious adverse events related to moxibustion.
Conclusions Moxibustion appears to be effective in treating IBS-D compared with pharmacological medications. However, further large, rigorously designed trials are warranted due to insufficient methodological rigor in the included trials.
1.2.1.3. Park 2013 ☆

Park JW, Lee BH, Lee H. Moxibustion in the management of irritable bowel syndrome: systematic review and meta-analysis. BMC Complement Altern Med. 2013;13:247. doi: 10.1186/1472-6882-13-247. [168397]

Purpose This systematic review and meta-analysis aimed at critically evaluating the current evidence on moxibustion for improving global symptoms of Irritable bowel syndrome (IBS).
Methods We searched Medline, EMBASE, the Cochrane Central Register of Controlled Trials, AMED, CINAHL, and CNKI databases for randomised controlled trials (RCTs) of moxibustion comparing with sham moxibustion,pharmacological medications, and other active treatments in patients with IBS. Trials should report global symptom improvement as an outcome measure. Risk of bias for each RCT was assessed according to criteria by the Cochrane Collaboration, and the dichotomous data were pooled according to the control intervention to obtain a risk ratio (RR) of global symptom improvement after moxibustion, with 95% confidence intervals (CI).
Results A total of 20 RCTs were eligible for inclusion (n = 1625). The risk of bias was generally high. Compared with pharmacological medications, moxibustion significantly alleviated overall IBS symptoms but there was a moderate inconsistency among studies (7 RCTs, RR 1.33, 95% CI [1.15, 1.55], I2 = 46%). Moxibustion combined with acupuncture was more effective than pharmacological therapy but a moderate inconsistency among studies was found (4 RCTs, RR 1.24, 95% CI [1.09, 1.41], I2 = 36%). When moxibustion was added to pharmacological médications or herbal medicine, no additive benefit of moxibustion was shown compared with pharmacological medications or herbal medicine alone. One small sham-controlled trial found no difference between moxibustion and sham control in symptom severity (mean difference 0.35, 95% CI [−0.77, 1.47]). Moxibustion appears to be associated with few adverse events but the evidence is limited due to poor reporting.
Conclusion This systematic review and meta-analysis suggests that moxibustion may provide benefit to IBS patients although the risk of bias in the included studies is relatively high.

1.2.2. Association with Chinese Herbal Medicine

1.2.2.1. Yan 2019 ★

Yan J, Miao ZW, Lu J, Ge F, Yu LH, Shang WB, Liu LN, Sun ZG. Acupuncture plus Chinese Herbal Medicine for Irritable Bowel Syndrome with Diarrhea: A Systematic Review and Meta-Analysis. Evid Based Complement Alternat Med. 2019. [197596].

PURPOSETo comprehensively evaluate the efficacy and safety of acupuncture combined with Chinese herbal medicine (CHM) in treating irritable bowel syndrome with diarrhea (IBS-D).
METHODS Relevant randomized controlled trials (RCTs) were systemically retrieved from electronic databases from inception to March 2018, including the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, EMBASE, China National Knowledge Infrastructure (CNKI), Chinese Biological Medical Database (CBM, SinoMed), China Science and Technology Journal Database (VIP), and Wan Fang Data. Meanwhile, pooled estimates, including the 95% confidence interval (CI), were calculated for primary and secondary outcomes of IBS-D patients. Besides, quality of relevant articles was evaluated using the Cochrane Collaboration's risk of bias tool, and the Review Manager 5.3 and Stata12.0 softwares were employed for analyses.
RESULTSA total of 21 RCTs related to IBS-D were included into this meta-analysis. Specifically, the pooled results indicated that (1) acupuncture combined with CHM might result in more favorable improvements compared with the control group (relative risk [RR] 1.29; 95% CI 1.24-1.35; P =0.03); (2) the combined method could markedly enhance the clinical efficacy in the meantime of remarkably reducing the scores of abdominal pain (standardized mean difference [SMD] -0.45; 95% CI -0.72, -0.17; P = 0.002), abdominal distention/discomfort (SMD -0.36; 95% CI -0.71, -0.01; P = 0.04), diarrhea (SMD -0.97; 95% CI -1.18, -0.75; P < 0.00001), diet condition (SMD -0.73; 95% CI -0.93, -0.52; P<0.00001), physical strength (SMD -1.25; 95% CI -2.32, -0.19; P = 0.02), and sleep quality (SMD -1.02; 95% CI -1.26, -0.77; P < 0.00001) compared with those in the matched groups treated with western medicine, or western medicine combined with CHM. Additionally, a metaregression analysis was constructed according to the name of prescription, acupuncture type, treatment course and publication year, and subgroup analyses stratified based on the names of prescriptions and acupoints location were also carried out, so as to explore the potential heterogeneities; and (3) IBS-D patients treated with the combined method only developed inconspicuous adverse events; more importantly, the combined treatment had displayed promising long-term efficacy.
CONCLUSIONSFindings in this study indicate that acupuncture combined with CHM is suggestive of an effective and safe treatment approach for IBS-D patients, which may serve as a promising method to treat IBS-D in practical application. However, more large-scale, multicenter, long-term, and high-quality RCTs are required in the future, given the small size, low quality, and high risk of the studies identified in this meta-analysis.

1.2.3. Liver Dispersing with Spleen Strengthening

1.2.3.1. Li 2016 ☆☆

Li Xiang-li, Liao Jian-qiong, Cai Jing-zhou, Wang Sheng-xu. [Clinically Randomized Control Trials of Liver Dispersing with Spleen Strengthening for Irritable Bowel Syndrome Dominated by Diarrhea: A Meta-analysis]. Journal of Clinical Acupuncture and Moxibustion. 2016;32(4):49-53. [182275].

ObjectiveThe clinically therapeutic effect of liver dispersing with spleen strengthening for irritable bowel syndrome by diarrhea was systematically analyzed to provide reference and assistance for its clinical treatment and research.
Methods By searching in the Cochrane Library, PubMed, Embase, CNKI, Wangfang, vIP, CBM, clinically randomized controlled trials (RCT) of liver dispersing with spleen strengthening for irritable bowel syndrome by diarrhea published from inception to April 2015 were collected while Revman 5. 2 software was applied to perform the Meta - analysis. Results: Ten studies involving 78 1 participants were included in our Meta - analysis.
ResultsThe results showed that liver dispersing with spleen strengthening (herbs, Chinese patent drug, acupuncture) had an advantage over western medicine in the treatment of IBS - D [ total efficacy: OR = 3. 94, 95 % CI (2. 58 - 6. 0 1), P< 0. 0 1 〕, and the symptoms of abdominal pain, abdominal distention and stool consistency were relieved, but the mental symptom was not significantly relieved.
ConclusionLiver dispersing with spleen strengthening (herbs, Chinese patent drug, acupuncture) is effective for IBS - D patients in relieving clinical symptoms, especially in the symptoms of abdominal pain, abdominal distention and stool consistency. It is safe and there is no serious adverse reaction.

1.3. Special Clinical Forms

1.3.1. Diarrhea-Predominant Irritable Bowel Syndrome

1.3.1.1. Jiang 2022

Retracted: Acupuncture and Moxibustion in the Treatment of Adult Diarrhea Irritable Bowel Syndrome: A Network Meta-analysis. Comput Math Methods Med. 2023 Jul 19;2023:9892851. https://doi.org/10.1155/2023/9892851

Jiang X, Guo X, Zhou J, Ye S. Acupuncture and Moxibustion in the Treatment of Adult Diarrhea Irritable Bowel Syndrome: A Network Meta-analysis. Comput Math Methods Med. 2022 Jun 28;2022:9919839. https://doi.org/10.1155/2022/9919839

ObjectiveThis study was aimed at comparing the clinical efficacy of acupuncture and moxibustion on irritable bowel syndrome complicated with diarrhea (IBS-D) in adults and providing guidance for clinical treatment.
Methods PubMed, The Cochrane Library, Embase, CBM, CNKI, and VIP and Wanfang databases were searched to obtain clinical randomized controlled trials (RCTs) on acupuncture and moxibustion in the treatment of IBS-D published from establishment of the database to August 5, 2021. Relevant data were extracted to assess the risk of bias in the included studies, and statistical software Stata 16.0 was used for meta-analysis.
Results Twenty-one studies were eventually included in the network meta-analysis (NMA), including 1626 patients with IBS-D and 8 therapeutic measures. NMA showed that acupuncture [OR = 0.35, 95%CI (0.25, 0.49), P < 0.05], warming needle moxibustion [OR = 6.34, 95%CI (2.83, 14.21), P < 0.05], acupuncture+sandwiched moxibustion [OR = 12.83, 95%CI (4.49, 36.64), P < 0.05], acupuncture+heat-sensitive moxibustion [OR = 9.86, 95%CI (1.77, 55.00), P < 0.05] were more effective than pinaverium bromide in the treatment of IBS-D. Cumulative ranking probability (SUCRA) showed that the comprehensive efficacy of acupuncture and moxibustion (86.8%) and quality of life (QOL) (70.4%) was the best, while the comprehensive efficacy of pinaverium bromide (2.1%) and QOL (16.3%) was the worst. GV20, GV29, ST 25, ST37, ST36 , SP6, LR3, and CV12 were used frequently.
Conclusion Acupuncture+sandwiched moxibustion has the best effect on improving the efficacy and QOL of IBS-D patients. Limited by the number and quality of studies, we still need a large sample, multicenter, and high-quality clinical trials to confirm our findings.
1.3.1.2. Guo 2020 ☆

Guo J, Xing X, Wu J, Zhang H, Yun Y, Qin Z, He Q. Acupuncture for Adults with Diarrhea-Predominant Irritable Bowel Syndrome or Functional Diarrhea: A Systematic Review and Meta-Analysis. Neural Plast. 2020. [215399]. doi

ObjectiveTo evaluate the clinical effectiveness and safety of acupuncture therapy in the treatment of diarrhea-predominant irritable bowel syndrome (IBS-D) or functional diarrhea (FD) in adults.
Method Five electronic databases-PubMed, EMBASE, CNKI, VIP, and Wanfang-were searched, respectively, until June 8, 2020. The literature of clinical randomized controlled trials of acupuncture for the treatment of IBS-D or FD in adults were collected. Meta-analysis was conducted by Using Stata 16.0 software, the quality of the included studies was assessed by the RevMan ROB summary and graph, and the results were graded by GRADE.
Result Thirty-one studies with 3234 patients were included. Most of the studies were evaluated as low risk of bias related to selection bias, attrition bias, and reporting bias. Nevertheless, seven studies showed the high risk of bias due to incomplete outcome data. GRADE's assessments were either moderate certainty or low certainty. Compared with loperamide, acupuncture showed more effectiveness in weekly defecation (SMD = -0.29, 95% CI [-0.49, -0.08]), but no significant improvement in the result of the Bristol stool form (SMD = -0.28, 95% CI [-0.68, 0.12]). In terms of the drop-off rate, although the acupuncture group was higher than the bacillus licheniformis plus beanxit group (RR = 2.57, 95% CI [0.24, 27.65]), loperamide group (RR = 1.11, 95% CI [0.57, 2.15]), and trimebutine maleate group (RR = 1.19, 95% CI [0.31, 4.53]), respectively, it was lower than the dicetel group (RR = 0.83, 95% CI [0.56, 1.23]) and affected the overall trend (RR = 0.93, 95% CI [0.67, 1.29]). Besides, acupuncture produced more significant effect than dicetel related to the total symptom score (SMD = -1.17, 95% CI [-1.42, -0.93]), IBS quality of life (SMD = 2.37, 95% CI [1.94, 2.80]), recurrence rate (RR = 0.43, 95% CI [0.28, 0.66]), and IBS Symptom Severity Scale (SMD = -0.75, 95% CI [-1.04, -0.47]). Compared to dicetel (RR = 1.25, 95% CI [1.18, 1.32]) and trimebutine maleate (RR = 1.35, 95% CI [1.13, 1.61]), acupuncture also showed more effective at total efficiency. The more adverse effect occurred in the acupuncture group when comparing with the dicetel group (RR = 11.86, 95% CI [1.58, 89.07]) and loperamide group (RR = 4.42, 95% CI [0.57, 33.97]), but most of the adverse reactions were mild hypodermic hemorrhage.
ConclusionAcupuncture treatment can improve the clinical effectiveness of IBS-D or FD, with great safety, but the above conclusions need to be further verified through the higher quality of evidence.
1.3.1.3. Deng 2017 ☆☆

Deng D, Guo K, Tan J1, Huang G, Li S, Jiang Q, Xie J, Xie H, Zhang Z, Chen Y, Peng L. [Acupuncture for diarrhea-predominant irritable bowel syndrome: a meta-analysis]. Zhongguo Zhen Jiu. 2017;37(8):907-912. [43743].

ObjectiveTo systematically evaluate the efficacy and safety of acupuncture on diarrhea-predominant irritable bowel syndrome (IBS) in the past five years.
MethodsOnline databases, including CNKI, VIP, WANFANG, PubMed, CBM, ScienceDirect OnSite, Cochrane Library, etc. were searched for randomized controlled trials (RCTs) of acupuncture for diarrhea-predominant IBS. Retrieval time was from January of 2011 to January of 2016. According to modified Jadad standard, the bias risk and quality assessment of each RCT included were evaluated by two researchers. RevMan 5.3 software was adopted for the meta-analysis.
ResultsTotally 17 RCTs were included with 1 333 patients. The result of meta-analysis indicated the total effective rate of clinical symptoms improvement in the acupuncture group or acupuncture combined with western medicine group was superior to that in the western medicine group (OR=3.92, 95% CI:2.83~5.43, P<0.01), and the funnel plot was basically symmetry. The result of meta-analysis showed 3-month recurrence rate: OR=0.22, 95% CI:0.12~0.41 (P<0.01), indicating the recurrence rate in the acupuncture group was lower than that in the western medicine group in three months.
Conclusions Acupuncture for diarrhea-predominant irritable bowel syndrome is superior to conventional treatment of western medication, which can improve the clinical symptoms and reduce the recurrence rate of patients.

1.3.2. Anxiety and depression in irritable bowel syndrome

1.3.2.1. Wang 2023

Wang X, Shi X, Lv J, Zhang J, Huo Y, Zuo G, Lu G, Liu C, She Y. Acupuncture and related therapies for the anxiety and depression in irritable bowel syndrome with diarrhea (IBS-D): A network meta-analysis of randomized controlled trials. Front Psychiatry. 2022 Dec 23;13:1067329. https://doi.org/10.3389/fpsyt.2022.1067329

Objective A growing number of clinical studies have suggested the value of acupuncture-related therapies for patients with irritable bowel syndrome with diarrhea (IBS-D), and the patient's mental state plays an important role, but there are many types of acupuncture-related therapies involved. This study aimed to evaluate the mental status, efficacy and safety of the different acupuncture-related therapies for IBS-D patients.
MethodsWe searched seven databases to collect randomized controlled trials of acupuncture-related therapies for IBS-D. After independent literature screening and data extraction, the quality of the final included literature was evaluated. Hamilton anxiety rating scale (HAMA), hamilton depression rating scale (HAMD), self-rating anxiety scale (SAS), and self-rating depression scale (SDS) was used as the primary outcome indicator. And the network meta-analysis (NMA) was performed by using Revman 5.4, Stata 15.0 and WinBUGS 1.4.3 software, and the surface under the cumulative ranking curve was conducted to rank the included interventions.
ResultsWe analyzed 24 eligible studies with 1,885 patients, involving eight types of acupuncture and related therapies along with comprehensive therapies. The NMA result shows that: for SAS scores, combined therapies were more efficacious than anti-diarrheal or antispasmodic (western medicine, WM) (SMD: -8.92; 95% CI: -15.30, -2.47); for SDS scores, combined therapies were more efficacious than WM (SMD: -8.45; 95% CI: -15.50, -1.41). For HAMA scores, moxibustion (MOX) was more efficacious than placebo (SMD: -8.66; 95% CI: -16.64, -0.38). For HAMD scores, MOX was more efficacious than all other included interventions. For response rate, MOX was more efficacious than the following interventions: acupuncture (ACU) (SMD:0.29; 95% CI:0.08,0.93), Chinese herb medicine (CH) (SMD:0.09; 95% CI:0.02,0.36), combined therapies (SMD:0.23; 95% CI:0.06, 0.85), electroacupuncture (EA) (SMD:0.06; 95% CI:0.01,0.33), warm acupuncture (WA) (SMD:22.16; 95% CI:3.53,148.10), WM (SMD:15.59; 95% CI:4.68,61.21), and placebo (SMD:9.80; 95% CI:2.90,45.51). Combined therapies were more efficacious than the following interventions: CH (SMD:0.39; 95% CI:0.19,0.80), WA (SMD:4.96; 95% CI:1.30,21.62), and WM (SMD:3.62; 95% CI:2.35,5.66). The comprehensive ranking results show that MOX, ACU, combined therapies, and EA had high SUCRA rankings involving different outcome indicators.
ConclusionMOX, ACU, combined therapies, and EA better alleviate anxiety and depression among IBS-D patients, and with a higher safety level, may be the optimal therapies. In addition, combining acupuncture-related treatments and other therapies also delivers a higher global benefit level.
1.3.2.2. Li 2022

Li HY, Chen Y, Hu ZY, Chen W, Tang HY, Yu ZY, Ye J. [Meta analysis of acupuncture and moxibustion for anxiety and depression in irritable bowel syndrome]. Zhen Ci Yan Jiu. 2022 Sep 25;47(9):821-9. Chinese. https://doi.org/10.13702/j.1000-0607.20210808

ObjectiveTo evaluate the effectiveness of acupuncture and moxibustion in the treatment of anxiety and depression in irritable bowel syndrome (IBS) by meta-analysis.
MethodsChina National Knowledge Infrastructure (CNKI), Wanfang Data, China Scientific Journal Database (VIP), China Biomedical Literature Service System (SinoMed), PubMed, Embase, and Cochrane Library were searched for randomized controlled trials (RCTs) on acupuncture and moxibustion in the treatment of IBS anxiety and depression from database inception to June 30, 2021. RevMan5.3 and Stata16.0 were used to conduct Meta-analysis of relevant outcome indicators.
ResultsA total of 11 RCTs were included in this study, involving 774 IBS patients (431 in the intervention group and 343 in the control group). Eight of them used manual acupuncture (MA) intervention, and the other three used electroacupuncture (EA) intervention. Meta-analysis showed that compared with the western medicine, MA improved the sedation-agitation scale (SAS) scores (MD=5.24, 95%CI=［3.49, 7.00］, P<0.000 01) and self-rating depression scale (SDS) scores (MD=8.50, 95%CI=［4.68, 12.32］, P<0.000 1) in IBS patients, and there was no significant difference between MA or EA and western medicine in the improvement of Hamilton anxiety rating scale (HAMA) scores (MD=1.10, 95%CI=［0.36, 2.56］, P=0.14) and Hamilton depression rating scale (HAMD) scores (MD=0.53, 95%CI=［0.89, 1.94］, P=0.47). In terms of total effective rates (RR=1.21, 95%CI=［1.12, 1.31］, P<0.000 01) and the irritable bowel syndrome severity scoring system (IBS-SSS) scores (MD=42.16, 95%CI=［27.40, 56.91］, P<0.000 01), both MA and EA therapy was superior to western medicine in alleviating gastrointestinal symptoms of IBS patients.
Conclusion MA and EA can improve the anxiety and depression of IBS patients, while the influence of other acupuncture and moxibustion interventions needs to be deeply explored with more high-quality RCTs.

2. Overviews of Systematic Reviews

2.1. Ma 2024

Ma YY, Hao Z, Chen ZY, Shen YX, Liu HR, Wu HG, Bao CH. Acupuncture and moxibustion for irritable bowel syndrome: An umbrella systematic review. J Integr Med. 2024 Jan;22(1):22-31. https://doi.org/10.1016/j.joim.2023.12.001

Backgound Irritable bowel syndrome (IBS) is a functional bowel disease characterized by abdominal pain or discomfort associated with altered bowel habits. Several clinical studies have demonstrated the effectiveness of acupuncture and moxibustion for IBS. Many systematic reviews of acupuncture and moxibustion for IBS have been published in recent years, but their results are not entirely consistent.
Objective To evaluate the methodological, reporting, and evidence quality of systematic reviews of acupuncture and moxibustion for IBS.
Methods Search strategy: Systematic reviews of acupuncture and moxibustion for IBS published before February 20, 2023 were searched in eight databases: PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure, Wanfang Data, VIP Database for Chinese Technical Periodicals, and China Biology Medicine. The keywords used for literature search were acupuncture, moxibustion, systematic review, meta-analysis, and irritable bowel syndrome. Inclusion criteria: Systematic reviews and meta-analyses of randomized controlled trials of acupuncture and moxibustion for IBS were included. Data extraction and analysis: Relevant information was independently extracted by two investigators. The A MeaSurement Tool to Assess systematic Reviews 2 (AMSTAR 2), Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020), and Grading of Recommendations Assessment, Development and Evaluation (GRADE) were used to evaluate the methodological quality, reporting quality and evidence quality, respectively.
Results A total of 342 studies were retrieved and 15 systematic reviews were included. The results of AMSTAR 2 showed low methodological quality in 2 studies and very low methodological quality in the remaining 13 studies, with main issues being failure to register a protocol, incomplete search strategy, not providing a list of excluded studies, incomplete consideration of the risk of bias in the included studies, and a failure to assess the publication bias. The results of PRISMA 2020 showed seriously deficient reporting quality of 2 studies, somewhat deficient reporting quality of 12 studies, and relatively complete reporting quality of 1 study, with the main problems being lack of a complete search strategy, non-availability of a list of excluded studies with justification for their exclusion, not conducting heterogeneity and sensitivity analyses, not evaluating the credibility of the evidence, and not registering the protocol. The results of GRADE showed that the quality of the evidence is low or very low.
Conclusion Most included systematic reviews interpreted findings to suggest that acupuncture and moxibustion have benefits for IBS. However, there is a need to improve the methodological, reporting and evidence quality of the systematic reviews. Larger, multicenter, rigorously designed randomized controlled trials and high-quality systematic reviews are required to obtain more robust evidence.

2.2. Wu 2019 ☆

Wu IXY , Wong CHL , Ho RST , Cheung WKW , Ford AC , Wu JCY , Mak ADP , Cramer H , Chung VCH. Acupuncture and related therapies for treating irritable bowel syndrome: overview of systematic reviews and network meta-analysis. Therap Adv Gastroenterol. 2019. [192630].

Background An overview of systematic reviews (SRs) and a network meta-analysis (NMA) were conducted to evaluate the comparative effectiveness of acupuncture and related therapies used either alone, or as an add-on to other irritable bowel syndrome (IBS) treatments.
Methods A total of eight international and Chinese databases were searched for SRs of randomized controlled trials (RCTs). The methodological quality of SRs was appraised using the AMSTAR instrument. From the included SRs, data from RCTs were extracted for the random-effect pairwise meta-analyses. An NMA was used to evaluate the comparative effectiveness of different treatment options. The risk of bias among included RCTs was assessed using the Cochrane risk of bias tool.
Results From 15 SRs of mediocre quality, 27 eligible RCTs (n = 2141) were included but none performed proper blinding. Results from pairwise meta-analysis showed that both needle acupuncture and electroacupuncture were superior in improving global IBS symptoms when compared with pinaverium bromide. NMA results showed needle acupuncture plus Geshanxiaoyao formula had the highest probability of being the best option for improving global IBS symptoms among 14 included treatment options, but a slight inconsistency exists.
ConclusionThe risk of bias and NMA inconsistency among included trials limited the trustworthiness of the conclusion. Patients who did not respond well to first-line conventional therapies or antidepressants may consider acupuncture as an alternative. Future trials should investigate the potential of (1) acupuncture as an add-on to antidepressants and (2) the combined effect of Chinese herbs and acupuncture, which is the norm of routine Chinese medicine practice.

2.3. Zhang 2014 ☆

Wei Zhang, Jian-Hua Sun, Li-Xia Pei, Xiao-Liang Wu, Jun-Ling Zhou, Lu Chen,. [Traditional chinese medicine for treatment of irritable bowel syndrome: an overview of systematic reviews and metaanalyses]. World Chinese Journal of Digestology. 2014;12:1747-175. [187063].

Objectives To evaluate the relevant systematic reviews/meta-analyses that focused on the traditional Chinese medicine (TCM) for treatment of irritable bowel syndrome (IBS).
Methods Databases including Cochrane Library, PubMed, AMED, Embase, CBM, CNKI, VIP and WanFang Data were searched from inception to November 2013 to collect the systematic reviews/meta-analyses that focused on the TCM for IBS. Two reviewers screened the literature according to the inclusion criteria and extracted the data. The AMSTAR was used to evaluate the quality of the included studies, and the GRADE system was used to evaluate the quality of evidence.
Results A total of 14 relevant systematic reviews/meta-analyses were included, of which 10 evaluated the efficacy of Chinese herbal medicine and 4 evaluated acupuncture and Moxibustion. AMSTAR scores were between 2 and 10 points. The results showed that TCM has advantage over conventional medicine in the treatment of IBS; however, the evidence quality is low.
Conclusions This research can provide some references for TCM treatment of IBS. Based on the quality level of GRADE evidence, the evidence user should make an evidence-based decision according to the real condition. TCM clinical research should, based on its own characteristics, select the appropriate research design methods, further develop high-quality clinical studies for the evaluation of Chinese medicine treatment of IBS and provide the high-quality evidence.

3. Clinical Practice Guidelines

⊕ positive recommendation (regardless of the level of evidence reported)
Ø negative recommendation (or lack of evidence)

3.1. Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS, Germany) und der Deutschen Gesellschaft für Neurogastroenterologie und Motilität (DGNM, Germany) 2021 ⊕

Layer P, Andresen V, Allescher H, Bischoff SC, Claßen M, Elsenbruch S, Freitag M, Frieling T, Gebhard M, Goebel-Stengel M, Häuser W, Holtmann G, Keller J, Kreis ME, Kruis W, Langhorst J, Jansen PL, Madisch A, Mönnikes H, Müller-Lissner S, Niesler B, Pehl C, Pohl D, Raithel M, Röhrig-Herzog G, Schemann M, Schmiedel S, Schwille-Kiuntke J, Storr M, Preiß JC; Collaborators:, Andus T, Buderus S, Ehlert U, Engel M, Enninger A, Fischbach W, Gillessen A, Gschossmann J, Gundling F, Haag S, Helwig U, Hollerbach S, Karaus M, Katschinski M, Krammer H, Kuhlbusch-Zicklam R, Matthes H, Menge D, Miehlke S, Posovszky MC, Schaefert R, Schmidt-Choudhury A, Schwandner O, Schweinlin A, Seidl H, Stengel A, Tesarz J, van der Voort I, Voderholzer W, von Boyen G, von Schönfeld J, Wedel T. Update S3-Leitlinie Reizdarmsyndrom: Definition, Pathophysiologie, Diagnostik und Therapie. Gemeinsame Leitlinie der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) und der Deutschen Gesellschaft für Neurogastroenterologie und Motilität (DGNM) – Juni 2021 – AWMF-Registriernummer: 021/016. Z Gastroenterol. 2021 Dec;59(12):1323-1415. https://doi.org/10.1055/a-1591-4794

Acupuncture and moxibustion can be used to improve quality of life in patients with IBS. [Recommendation grade 0, consensus]
Complementary or alternative forms of therapy (acupuncture, TCM, homeopathy, etc.) should not be used in childhood IBS. [Recommendation grade B, consensus]

3.2. Japanese Society of Gastroenterology (JSG, Japan) 2020 ⊕

The Japanese Society of Gastroenterology. [Evidence-based Clinical Practice Guidelines For Irritable Bowel syndrome, 2020] . 2nd ed. Tokyo: Nankodo Co, Ltd; 2020 [in Japanese] . Cited by Okawa Y, Yamashita H, Masuyama S, Fukazawa Y, Wakayama I. Quality assessment of Japanese clinical practice guidelines including recommendations for acupuncture. Integr Med Res. 2022 Sep;11(3):100838. https://doi.org/10.1016/j.imr.2022.100838

IBS. Weak recommendation (to use)

3.3. Canadian Association of Gastroenterology 2019 Ø

Moayyedi P, Andrews CN, MacQueen G, Korownyk C, Marsiglio M, Graff L, Kvern B, Lazarescu A, Liu L, Paterson WG0, Sidani S, Vanner S. Canadian Association of Gastroenterology Clinical Practice Guideline for the Management of Irritable Bowel Syndrome (IBS). J Can Assoc Gastroenterol. 2019;2(1):6-29. [197158].

15: We recommend AGAINST offering acupuncture to IBS patients to improve IBS symptoms. GRADE: Strong recommendation, very low-quality evidence.

3.4. British Society of Gastroenterology 2018 Ø

Lamb CA, Kennedy NA, Raine T, Hendy P, Smith PJ, Limdi JK et al. British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults. British Society of Gastroenterology. 2018;:386p. [197080].

Anecdotical evidence supports the use of acupuncture although there are no controlled trials and in this case blinding is an obvious problem.

3.5. Sociedad Española de Patología Digestiva (SEPD, Espagne) 2016 Ø

Mearin F, Ciriza C, Mínguez M, Rey E, Mascort JJ, Peña E, Cañones P, Júdez J. Clinical Practice Guideline: Irritable bowel syndrome with constipation and functional constipation in the adult. Rev Esp Enferm Dig. 2016;108(6):332-63. [98987].

No evidence supports recommending acupuncture to improve symptoms or quality of life in patients with IBS-C or FC.

3.6. World Gastroenterology Organisation (WGO) 2015 Ø

Irritable Bowel Syndrome: a Global Perspective World Gastroenterology Organisation. 2015:28p. [196753].

A systematic review of trials of acupuncture was inconclusive due to heterogeneous outcomes. Further research is needed before any recommendations on acupuncture or herbal therapy can be made.

3.7. National Institute for Health and Care Excellence (NICE, UK) 2015 Ø

National Collaborating Centre for Nursing and Supportive Care. Irritable bowel syndrome in adults: diagnosis and management of irritable bowel syndrome in primary care. London (UK): National Institute for Health and Care Excellence (NICE). 2015;37P. [165730].

The use of acupuncture should not be encouraged for the treatment of IBS.[2008]

3.8. World Gastroenterology Organisation (WGO) 2009 Ø

WGO Global Guideline; Syndrome de l’intestin irritable : Une approche globale World Gastroenterology Organisation Global Guidelines. 2009. 26P. [178703].

Une revue systématique des études sur l’acupuncture s’est révélée peu concluante en raison des résultats hétérogènes. D’autres études sont nécessaires avant que l’on puisse faire des recommandations sur l’acupuncture ou la phytothérapie.

4. Randomized Controlled Trials

4.1. Sources

a = Chao 2014
b = Park 2013
c = Pei 2012
d = Manheimer 2012
e = Lim 2006

4.2. List

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