Moxibustion For Treating Rheumatoid Arthritis:A Systematic Review And The Therapeutic Mechanism Of Moxibustion Treatment With The Use Of Proteomic Analysis

Objective(1) The purpose of this systematic review was to evaluate the available evidence from randomized controlled trials (RCTs) of moxibustion for treating patients with rheumatoid arthritis (RA).(2) To examine the possible impact of moxibustion on the serum proteome of the collagen-induced arthritis (CIA) rat model.Materials and methods(1) Seven Chinese and English databases were searched to November 2013 from their inception. Eligible RCTs were included if moxibustion was used either alone or in combination with Western medicine for treating rheumatoid arthritis. Study selection, data extraction, and validation was performed independently by two reviewers. Cochrane criteria for risk of bias was used to assess the methodological quality of the trials.(2) Thirty-six male Sprague-Dawley rats were included in this experiment. The CIA animal model was prepared by injection of type Ⅱ bovine collagen in Freund’s adjuvant on the first and seventh day. The 36 rats were randomly divided into 6 groups:(CIA+moxi) Ⅰ group, (CIA+moxi) Ⅱ group, (CIA+moxi) Ⅲ group, CIA Ⅰ group, CIAⅡgroup, and the CIA Ⅲ group. Moxibustion was administered daily at ST36 and BL23. Arthritis score was used to assess the severity of arthritis. At the end of each 7 day treatment, blood samples from the control group and the CIA+moxi group were collected. After removal of high abundance proteins from serum samples, two-dimensional gel combined with matrixassisted laser desorption ionisation time-of-flight MS/MS (MALDI-TOF-MS/MS) techniques were performed to examine serum protein expression patterns of the CIA rat model with and without moxibustion treatment. In addition, the relevant proteins were further analysed with the use of bio informatics analysis.Results(1) Eight RCTs met the inclusion criteria, and most were of low methodological quality.① response rate:Meta-analysis showed favorable effects of moxibustion on the response rate, either alone [RR=1.18,95%CI(1.03,1.35), p=0.02; heterogeneity:Chi2= 1.11,p= 0.77,I2= 0%]or the combination with Western medicine therapy [RR=1.28,95%CI(1.12,1.47),p= 0.0004; heterogeneity:. Chi2= 1.96, p= 0.58,12= 0%].② ACR rate:When compared with Western medicine therapy, Western medicine plus moxibustion therapy showed a favorable statistically significant effect on a reduction on American College of Rheumatology(ACR)50 [RR=1.57,95%CI(1.25,1.99), p= 0.0001;heterogeneity:Chi2= 2.87, p= 0.58,I2= 0%], whereas it failed to do so on American College of Rheumatology (ACR)20.③ DAS28:Additionally, when compared with western medicine therapy alone,meta-analysis of three RCTs suggested favorable but no statistically significant effects of moxibustion plus western medicine on the control of disease activities of rheumatoid arthritis [MD=-0.45,95%CI(-0.89,-0.01), p= 0.05].(2) Therapeutic mechanism of moxibustion treatment with the use of proteomic① Moxibustion significantly decreased arthritis severity in the rats in the CIA+moxi III group, when compared with the rats in the CIA III group.35 days after the first immunization (p=0.001).② Seventeen protein spots which changed>1.33 or<0.77 at p<0.05 using Bonferonni correction for multiple testing were found to be common to all three comparisons, and these proteins were used for classification of functions using the Gene Ontology method. Consequently, with the use of the Ingenuity Pathway Analysis, the top canonical pathways.③ 17 and moxibustion intervention related protein using GO analysis. A total of 4 cell locations,7 molecular functions and 3 biological processes were identified. In cell location, ranked the top three, respectively is cytoplasmic (62%), intercellular space (19%) and other (13%); in molecular function, ranked the top three are enzyme (38%), other (25%) and transporter (13%); in biological processes, ranked the top three are metabolic processes (56%), immune response (31%), and the cell response (13%).④ The 17 and moxibustion related protein by IPA analysis. Identified four enrichment of the highest signal pathway:Huntington’s disease signalling and endothelial nitric oxide synthase (eNOS) signalling, aldosterone signalling in epithelial cells and the unfolded protein response.⑤ The PRDX1 and IP3R as the two candidate proteins were verified by reverse ELISA method. Compared with the model group, the moxibustion group could significantly improve the protein expression level of PRDX1 and p<0.05 (IP3R) in first weeks, second weeks and third weeks after intervention. Therefore, through the reverse validation experiments of this ELISA method, we can see that the two candidate protein expression levels are up to the trend and the results of the mass spectrometry analysis are consistent, with strong reliability.Conclusions(1) It is difficult to draw firm conclusions on whether moxibustion is an effective intervention for treating RA due to the small sample size of eligible RCTs and the high risk of bias among the available RCTs. Further rigorous RCTs are warranted but need to overcome methodological shortcomings of the existing evidence.(2) Using the proteomics technique, we have identified novel candidate proteins that may be involved in the mechanisms of action underlying the beneficial effects of moxibustion in rats with CIA. Our findings suggest that immune responses and metabolic processes may be involved in mediating the effects of moxibustion. Moreover, periodxiredoxin I (PRDX1) and inositol 1,4,5-triphosphate receptor (IP3R) may be potential targets.