| Objective: Randomized controlled trials(RCTS)of acupuncture combined with medication in the treatment of Allergic rhinitis(AR)were selected as the research objects,and the quality of the included studies was evaluated by the Cochrane methodological evaluation tool of evidence-based medicine.Based on the GRADE evidence grading system,the evidence levels of the main outcome indicators were divided.At the same time,conventional meta-analysis was used to compare the therapeutic effects of acupuncture + Chinese medicine VS Chinese medicine,acupuncture + Chinese medicine VS acupuncture,acupuncture + western medicine VS western medicine and acupuncture + western medicine VS acupuncture.Meta regression and subgroup analysis were used to identify possible sources of heterogeneity.This study provides systematic evidence for the future clinical decision-making of acupuncture combined with medication in the treatment of AR.Methods:1.Literature search: Chinese Biomedical Science(CBM)(1979-2023),China National Knowledge Infrastructure(CNKI)(1979-2023),Wan Fang(1998-2023),VIP(1989-2023),Pub Med(1966-2023)and web of were systematically searched science database(1963-2023)and Cochrane Library database of randomized controlled clinical trials.The search deadline was February 10,2023.2.Literature screening and extraction: Note Express3.7.0 software was used for the initial screening,and duplicate literature was excluded.The second manual duplicate check was carried out according to the author,title and other basic information.Re-screening: titles and abstracts were initially scanned to exclude articles that were obviously inconsistent with this study.Such as: experimental study,case report,etc.Final screening: For studies whose inclusion could not be determined,the full text was chosen to be downloaded to decide whether to exclude.For example,self-control test and so on.Identification of included studies: The number of included RCTS was determined according to prespecified inclusion and exclusion criteria.WPS Table 11.1.0 software was used for data extraction.3.Bibliometrics: Microsoft excele form was used to extract,collate and analyze the name data of acupoints,Chinese herbs and prescriptions in the included literatures.4.Quality assessment: The methodological quality of RCTS was evaluated using the Cochrane risk of bias tool.5.GRADE of evidence quality: According to the outcome indicators,the evidence quality of the included randomized controlled trials was evaluated by GRADE pro3.6 software,which was divided into four levels:high,medium,low and very low,and the level of evidence was strictly evaluated.6.Statistical analysis6.1General Meta analysis Rev Man5.4.1 software was used for meta-analysis.Relative risk(RR)was used to analyze the binary data.The standardized mean difference(SMD)was used to analyze the continuous data,and the effect size was analyzed with 95% confidence interval(CI).P≤0.05 was considered statistically significant.Forest plots and funnel plots were also made.The size and sources of heterogeneity among the included studies were analyzed.The magnitude of I2 values and P values represent the degree of heterogeneity.If P>0.1 and I2≤50%,the heterogeneity between studies was considered to be small or no,and the fixed effect model was selected for statistical analysis.If I2 > 50%,the random effects model was used.For those with large heterogeneity,the possible sources of heterogeneity were mainly considered from three aspects: clinical,methodological and statistical.6.2Meta Regression Stata12.0 software was selected for subgroup analysis of data.The relative risk(RR)of binary data selection was analyzed.95%CI was used for all effect sizes,and P≤0.05 was the standard for statistical significance.The size and source of heterogeneity among included studies were analyzed and determined.The values of I2 and P represent the degree of heterogeneity.For those with large heterogeneity,the source of heterogeneity will be inferred.Results:1.Literature analysis: A total of 199 RCTS on the combined treatment of acupuncture and medication for AR were included in this study.Through the analysis of the rules of acupoint selection in the included literatures,72 acupoints were selected,and the top 10 points were selected according to the order of frequency: Feishu(BL 13)(n=101),Yingxiang(n=93),Yintang(n=74),Dazhui(n=74),Zusanli(ST 36)(n=70),Hegu(n=60),Shenshu(BL 23)(n=56),Pishu(n=50),Fengmen(n=38),Fengchi(n=22);A total of 33 kinds of prescriptions were used in the literature,and the top three were selected according to the frequency: Yupingfeng powder(n=5),Sitizhiqiu Decoction(n=3),and Yiqi Wenyang decoction(n=3).According to the analysis of the use of traditional Chinese medicine in the literature,101 Chinese herbs were used in the literature,and the top 10 were selected according to the frequency: Radix asarum(n=80),Astragalus membranaceus(n=75),Radix parvosa(n=66),Atractylodes atractylodes(n=63),Angelica Dahurica(n=61),Radix sinensis(n=59),Xanthium fructus(n=59),Liquorice(n=58),white mustard(n=37),Schisandra chinensis(n=34).2.Methodological quality assessment: A total of 199 RCTS were included in this study,92 of which provided detailed randomized methods.Twenty-one RCT studies reported specific allocation concealment methods.Three RCT studies provided detailed introduction of blinding to investigators and subjects.Six RCT studies mentioned the blinding of study outcome evaluation.The outcome data of 182 RCT studies were complete.Two RCT studies had selective reporting,and the description of other risks of bias was not enough.The quality of the included studies was generally low,and most of them were high risk evaluation,indicating that the methodological quality of the included RCT studies was generally poor.3.Grading of evidence quality:(1)acupuncture plus western medicine versus western medicine: ending index GRADE rating: the total effective rate of the intermediate,RQLQ,TNSS,TNNSS,Ig E and EOS as "?○○○" very low level.All the six outcome measures had limitations of the study.(2): acupuncture plus western medicine vs acupuncture ending index GRADE rating: the total effective rate,TNSS,TNNSS for low-level,RQLQ,Ig E and EOS as "?○○○" very low level.All the six outcome measures had limitations of the study.(3)acupuncture + vs Chinese materia medica: ending index GRADE rating:the total effective rate of "???○" intermediate,RQLQ and Ig E for low-level,TNSS and EOS as "?○○○" very low level.All the five outcome measures had limitations of the study.(4)acupuncture and moxibustion plus Chinese medicine vs acupuncture:ending index GRADE rating: the total effective rate,RQLQ,TNSS and Ig E for "??○○" low-level,EOS,"?○○○" extremely lowly.All the five outcome measures had limitations of the study.4.Routine meta-analysis4.1 Meta-analysis of acupuncture + Western medicine vs Western medicine A total of 49 studies involving 4999 patients were included in this study.Eighteen studies involving 1415 patients were included in RQLQ.TNSS included 12 studies with 1364 patients.TNNSS included 9 studies with1136 patients.Ig E included 11 studies with 904 patients.EOS included2 studies with 138 patients.Six outcome indicators including total effective rate,RQLQ,TNNS,TNNSS,Ig E and EOS were analyzed.The results of meta-analysis of total effective rate showed that RR=1.21,95%CI[1.16,1.26],acupuncture + western medicine was superior to western medicine.The results of meta-analysis of RQLQ scores showed that SMD=-1.60,95%CI[-2.17,-1.02],in terms of RQLQ score,acupuncture + western medicine score was lower than western medicine score.The results of meta-analysis of TNSS scores showed that SMD=-1.60,95%CI[-2.22,-0.97].In terms of TNSS score,acupuncture + western medicine score was lower than western medicine score.The results of meta-analysis of TNNSS scores showed that SMD=-0.70,95%CI[-0.97,-0.42].In terms of TNNSS score,acupuncture +western medicine score was lower than western medicine score.The results of meta-analysis of Ig E score showed that SMD=-1.30,95%CI [-1.91,-0.68].In terms of TNNSS score,acupuncture + western medicine score was lower than western medicine score.The results of meta-analysis of EOS showed that SMD=-0.14,95%CI[-0.48,0.19].In terms of EOS score,acupuncture +western medicine score was lower than western medicine score.4.2 Meta analysis of acupuncture + Western medicine VS acupuncture Nine studies involving 645 patients were included in this study.Four studies involving 241 patients were included in RQLQ.TNSS included 1 study with 60 patients.TNNSS included 1 study with 74 patients.Ig E was included in 2 studies with 150 patients.EOS included 1 study with 4patients.Six outcome indicators including total effective rate,RQLQ,TNNS,TNNSS,Ig E and EOS were analyzed.The meta analysis of the total effective rate showed that RR=1.18,95%CI [1.04,1.33],acupuncture +western medication was superior to acupuncture;The results of meta-analysis of RQLQ showed that SMD=-0.50,95%CI [-1.06,0.05],in terms of RQLQ score,acupuncture + western medicine score was lower than that of acupuncture;The results of meta-analysis of TNNS showed that SMD=-0.80,95%CI[-1.33,-0.27].In terms of TNSS score,acupuncture +western medicine score was lower than that of acupuncture.The results of meta-analysis of TNNSS showed that SMD=-0.63,95%CI[-1.10,-0.17].In terms of TNNSS score,acupuncture + western medicine was lower than acupuncture.Meta-analysis results of Ig E showed that SMD=-0.98,95%CI[-2.27,0.31],in terms of Ig E score,acupuncture + western medicine score was lower than that of acupuncture.The results of meta-analysis of EOS showed that SMD= 0.35,95%CI[-0.29,0.99].In terms of EOS score,there was no significant difference in reducing EOS levels between the experimental group and the control group.4.3 Meta analysis of acupuncture + Chinese medicine VS Chinese Medicine Thirty-six studies involving 3367 patients were included in this study.Eight studies involving 667 patients were included in RQLQ.TNSS included 3 studies with 216 patients.TNNSS included 0 studies with 0patients.Ig E included 7 studies with 527 patients.EOS included 1 study with 64 patients.Five outcome indicators including total effective rate,RQLQ,TNNS,Ig E and EOS were analyzed.The meta analysis of the total effective rate showed that RR=1.17,95%CI[1.13,1.21],acupuncture +Chinese medicine was superior to Chinese medicine.The results of meta-analysis of RQLQ showed that SMD=-2.09,95%CI[-3.21,-0.98].In terms of RQLQ score,acupuncture + TCM score was lower than TCM score.The results of meta-analysis of TNNS showed that SMD=-0.96,95%CI [-1.63,-0.29],in terms of TNSS score,acupuncture + TCM score was lower than that of TCM score.The results of meta-analysis of Ig E showed that SMD=-1.14,95%CI [-2.06,-0.21],in terms of Ig E score,acupuncture + TCM score was lower than that of TCM.The results of meta-analysis of EOS showed that SMD=-2.18,95%CI [-2.81,-1.56],acupuncture + TCM score was better than TCM score in terms of EOS score.4.4 Meta analysis of acupuncture + Traditional Chinese medicine VS acupuncture A total of 49 studies involving 4999 patients were included in this study.Eighteen studies involving 1415 patients were included in RQLQ.TNSS included 12 studies with 1364 patients.TNNSS included 9 studies with1136 patients.Ig E included 11 studies with 904 patients.EOS included2 studies with 138 patients.Five outcome indicators including total effective rate,RQLQ,TNNS,Ig E and EOS were analyzed.The meta analysis of the total effective rate showed that RR=1.27,95%CI [1.13,1.43],acupuncture + traditional Chinese medicine was better than acupuncture alone.The results of meta-analysis of RQLQ showed that SMD=-2.03,95%CI[-2.97,-1.08].In terms of RQLQ score,acupuncture + TCM score was lower than that of acupuncture.The results of meta-analysis of TNNS showed that SMD=-1.27,95%CI [-2.78,0.24].In terms of TNSS score,acupuncture + TCM score was lower than that of acupuncture.The results of meta-analysis of Ig E showed that SMD=-0.02,95%CI[-0.23,0.20],in terms of Ig E score,acupuncture + TCM score was lower than acupuncture score.The results of meta-analysis of EOS showed that SMD=-1.75,95%CI [-2.33,-1.16].In terms of EOS score,acupuncture + traditional Chinese medicine was lower than acupuncture.5.Meta regression Through meta-regression,it was found that intervention methods were the source of heterogeneity in the pooled analysis of effective rates.Subgroup analysis of acupuncture plus western medicine vs western medicine showed that: The results of heterogeneity test were P = 0.01,I2 = 76.7%,which meant that the choice of intervention method would affect the results of Meta-analysis.The effect size was 1.21 and significant(Z=10.55,P<0.0001),which reached a large effect size.The change of intervention methods was the source of heterogeneity.The results of heterogeneity test of owner analysis of acupuncture + TCM vs TCM were P = 0.34,I2 = 0%,and no significant heterogeneity was found between groups.Meta-analysis results,combined all results,the effect size was 1.27 and significant(p=0.006),which reached a large effect size,indicating that the change of intervention methods was the source of heterogeneity.Conclusion:1.Through bibliometric analysis,it is concluded that the acupoints of acupuncture and moxibustion for AR are mainly Feishu(BL 23),Yingxiang(BL 21),Yintang(BL 29),etc.,which are mainly used for tonifying lung and qi,dispelling wind,dispelling cold and clearing nasal orifices.The selected Chinese herbs were asarone,Astragalus membranaceus,windstorm and Atractylodes atractylodes,which were mainly for relieving surface,dispersing cold,tonifying qi and tonifying kidney.The selected prescriptions were mainly Yupingfeng powder,Sidi Zhiqiu decoction,Yiqi Wenyang decoction,which were mainly beneficial to Yiqi Wenyang,tonifying lung and kidney.2.At present,the quality of RCT studies of combined acupuncture and medicine therapy for AR at home and abroad still needs to be improved,and the GRADE evidence Grade of each outcome index is generally low.It is suggested that future clinical studies should be reported in strict accordance with the bias risk assessment tool recommended by Cochrane and the GRADE evidence grading system.3.According to the Meta analysis,the combination of acupuncture and Chinese medicine or acupuncture and western medicine in the treatment of AR has better total effective rate,RQLQ,TNSS,TNNSS,Ig E and EOS score improvement than other single treatment.4.Meta-regression analysis showed that the source of heterogeneity was basically confirmed.Further RCTS are unlikely to change the conclusions. |
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