Acupuncture for Acute Rhinitis.

Acupuncture for Acute Rhinitis.

Evidence-based medicine, as Dr. Novella realized, fails when applied to therapies that are not based in reality. As a result he coined the phrase, and idea, of science-based medicine.

The inadequacy of evidence-based medicine often rears its head in guidelines, where fantasy based therapies sneak in based on flawed evidence.

For example, Clinical Practice Guideline Allergic Rhinitis, where they say at lucky

STATEMENT 13. ACUPUNCTURE: Clinicians may offer acupuncture, or refer to a clinician who can offer acupuncture, for patients with AR who are interested in nonpharmacologic therapy. Option based on RCTs with limitations, observational studies with consistent effects, and a preponderance of benefit over harm.

They do not mention who is involved with writing with each sections recommendation, but I would wager their acupuncturist had some input into the positive recommendation.

 

They suggest the effects of acupuncture are uncertain:

The mechanism of action of acupuncture in the treatment of AR is unknown. Studies suggest that acupuncture inhibits cytokine synthesis, such as interleukin–10 in patients with AR and interleukin–6 and interleukin–10 in patients with asthma; however, it remains unclear whether these findings correlate with clinical effect.

Oh. Cytokines.  And I thought acupuncture worked by releasing endorphins. As is so often the case these guidelines fail to take into consideration the extensive literature that the effects of acupuncture are from theatrical placebo: i.e. the patient convincing themselves they are improved when they are not. Like all placebos, the effect is only seen for subjective endpoints, never for objective endpoints.

As is the case in the AR literature the positive studies were from China, where there has never been a negative acupuncture study published.

In the real world when an intervention is equal to placebo, we declare the intervention worthless. In the pseudo-medical world, when an intervention is equal to placebo, it works:

No significant differences were shown in RMS between the real acupuncture treatment group and the sham acupuncture treatment group. No side effects were observed for both groups. The results indicate that acupuncture is an effective and safe alternative treatment for the management of SAR.

and

The active acupuncture group exhibited a significant change in the total non-nasal symptom score (TNNSS) compared with the waitlist (difference: –0.78, 95% CI: –1.22, –0.34, P = 0.0002), but not the sham acupuncture group (difference; 0.15, 95% CI: –0.21, 0.5, P = 0.56). Both active and sham acupuncture treatments resulted in significant improvements in TNSS and TNNSS compared to baseline.

and often the results of acupuncture are so minimal that it is probably more random noise and poor blinding since

the improvements may not be clinically significant.

Going back to the original literature, rather than the summary, reveals  less than impressive effect from acupuncture, supporting the conclusion that

Meta-analyses provided no clear evidence for the efficacy of acupuncture in rhinitis and asthma.

There is no reason acupuncture should work for AR (or any disease), no consistent effect greater than placebo and reviewed by a practitioner with a bias in favor of acupuncture. I am not impressed.

Guidelines, rather than hiring a proponent of pseudo-medicine like an acupuncturist, really need to include someone versed in science-based medicine to review the pseudo-medicine. That way the shruggie attitude of what’s the harm does not waste the patients time and money. Where the authors see a

preponderance of benefit over harm.

I see no benefit or reason for benefit for acupuncture and only the potential for harm.

They suggest that there is a

Quality improvement opportunity: Increased awareness of acupuncture as a treatment option for AR.

even though they conclude

Research is needed to determine the safety and efficacy of acupuncture for AR. There is a relative paucity of data in the English-language literature regarding the use of complementary and integrative medicine for AR. As such, specific recommendations for or against these treatments could not be made. Higher levels of evidence regarding these therapies need to be obtained through well-designed clinical trials and/or systematic reviews of existing data.

The summary: no mechanism for actions, lousy studies, lets use acupuncture more. And they do not really know what they are recommending,  since acupuncture is a

family of procedures involving the stimulation of points on the body. The technique that has been most often studied involves penetrating the skin with thin, solid, metallic needles that are manipulated by hand or by electrical stimulation.

So which style to use?

I don’t think so. As Drs. Colquhoun and Novella have so eloquently noted

The best controlled studies show a clear pattern, with acupuncture the outcome does not depend on needle location or even needle insertion. Since these variables are those that define acupuncture, the only sensible conclusion is that acupuncture does not work. Everything else is the expected noise of clinical trials, and this noise seems particularly high with acupuncture research. The most parsimonious conclusion is that with acupuncture there is no signal, only noise.

The interests of medicine would be best-served if we emulated the Chinese Emperor Dao Guang and issued an edict stating that acupuncture and moxibustion should no longer be used in clinical practice.

Florida retracts cease and desist order and fine a...
Points of Interest 03/27/2015

Related Posts