Asthma (2018)

Overview

Key points

• Recent studies have shown that acupuncture, in combination with conventional medication, may have a positive effect on symptom control and improve quality of life in patients with asthma [2,6,7]
• In addition, the lack of significant adverse effects in current trials,6 and the cost-effectiveness evidence [7,8] support the use of acupuncture for the treatment of asthma
• It is difficult to draw firm conclusions due to the paucity of large well-designed trials and the absence of recent systematic reviews
• A systematic review showed that the effectiveness of moxibustion was similar to Seretide at 3 or 6 months in the treatment of bronchial asthma [5]
• Asthma is a widespread, long-term  condition that affects the airways and is associated with significant morbidity and mortality [1-3]
• Compliance with inhaled medication is a problem and a treatment free of side effects is desirable [2,4,5]

Background
Asthma is thought to affect approximately 300 million people worldwide [1] and causes significant morbidity and mortality. [2,3] The condition is associated with a sizable economic burden, due in the majority to costs of hospitalization and medication, as well as asthma-related work and school absences.[7,9]

The first choice treatments for mild-to-moderate asthma are corticosteroids and short-acting beta-2 agonists, but compliance with daily inhaled medication can be problematic.[2,4] Corticosteroid use is also associated with adverse events, and it is the lack of such side effects that makes acupuncture a promising option for the management of asthma.[5,6] Evidence-based complementary approaches to asthma, such as acupuncture, could form part of a comprehensive care plan including conventional therapies and regular follow-up.[3]

The effectiveness of acupuncture treatment

The evidence of the effectiveness of acupuncture in the treatment of asthma is inconclusive and there is a need for large, well-designed trials.

Systematic reviews
The most recent systematic review or meta-analysis for acupuncture with adult asthma was a Chinese language paper published in 2010. It assessed the effectiveness of both acupuncture and moxibustion. The total effective rate with acupuncture was significantly superior to control, and significant differences were also observed between the two groups for some measures of airflow obstruction.[10]

Two systematic reviews of acupuncture for the management of asthma in children have concluded that the effectiveness is unclear due to the methodologic variability of the current trials.[11,12] However, the results of one of the reviews suggested that acupuncture may have beneficial effects on peak expiratory flow (PEF) or PEF variability in children with asthma, and the authors called for larger trials to be conducted. Two randomised controlled trials (RCTs) included in the review showed significant improvement in PEF variability for acupuncture (traditional and laser) compared with control. One trial showing significant improvement in asthma-specific anxiety levels, but no significant differences were observed in other lung function parameters or quality of life. [12]

For acupressure there has been a systematic review of RCTs for the management of allergic respiratory diseases.  No clear conclusions could be drawn due to the limited number of high quality studies currently available. [13]

For moxibustion in the treatment of bronchial asthma, a systematic review included RCTs where heat-sensitive acupuncture points are gently warmed with a moxa stick. They found that moxibustion was not significantly different to Seretide (fluticasone propionate and salmeterol) at 3 or 6 months in terms of effective rate, parameters of pulmonary function, and the asthma control score. [5]

Additional randomised controlled trials
These trials were more recent than the reviews described above.

The benefit of adding acupuncture to routine care in people with allergic asthma was assessed in a large, high quality study where patients were randomized to an acupuncture or control group, or were assigned to a non-randomized acupuncture group. This study took a pragmatic approach, aiming to evaluate acupuncture in a manner that would reflect as closely as possible the conditions of routine medical practice. In the randomized portion of the study, acupuncture treatments led to an improvement in quality of life compared with the control group which was maintained to 6 months. Those in the non-randomized acupuncture group demonstrated similar improvements to the randomized acupuncture group. [2]

Adding real acupuncture to standard care of asthma in adults significantly reduced the use of rescue medication and led to significant improvements in functional capacity, physical aspects, general health status and vitality. After both sham and real acupuncture treatment, patients experienced significantly less coughing, wheezing and shortness of breath.6

Considerable improvements in quality of life were observed when acupuncture was added to the routine treatment of allergic bronchial asthma and in the following 3 months. [7]

Allergic rhinitis and asthma
The majority of asthma cases are due to allergic conditions7 and asthma is closely related to allergic rhinitis (AR). There is a body of evidence supporting the effectiveness of acupuncture in the management of AR, with an improvement in symptoms and quality life, and a reduction in medication use.[2,14-16] An RCT in adults with persistent AR found that acupuncture modulated mucosal immune response in the upper airway.[16] The American guideline on the management of AR recommends that clinicians offer acupuncture to those interested in nonpharmacologic therapy.[17] [Refer to the BAcC Fact Sheet on Allergic Rhinitis for further details].

Safety of acupuncture treatment
A systematic review of acupuncture in children for several conditions, including asthma, found that it was generally well tolerated and no fatal side effects were reported.11 One review comprising 22 RCTs reported that the risk of adverse events and serious adverse events occurring from acupuncture in children is estimated to be 1.55/100 and 5.36/10,000 treatments, respectively.[11,18] It has been suggested that serious adverse events in acupuncture are likely to be due to substandard practice, and that acupuncture can be considered safe when performed by appropriately trained practitioners.[11,19] A systematic review of RCTs of acupressure in respiratory diseases found that it is safe for symptomatic relief of allergic rhinitis and asthma, although larger studies are required to confirm this.[13]

Is acupuncture cost-effective?
Studies suggest that acupuncture may be cost-effective for the management of asthma.[7,8] Acupuncture does increase costs compared with usual care but it results in substantial improvements in quality of life.  In this German study, most acupuncture was given by physicians and the costs relate to these extra visits. The authors concluded that acupuncture is a useful and cost-effective add-on treatment for bronchial asthma.[7]