Acupuncture and Allergies
By Judith L. Balk, MD, MPH, FACOG. Dr. Balk is Associate Professor, Magee-Women's Hospital, University of Pittsburgh; she reports no financial relationship to this field of study.
Allergic rhinitis affects 10%-20% of the population, and it greatly affects quality of life.1,2 Seasonal allergic rhinitis, otherwise known as hay fever, is a common condition, affecting 10%-15% of the population.3 Complications of allergic rhinitis include acute and chronic sinusitis, hearing impairment, sleep apnea, and daytime fatigue.1 Currently used medications for allergic rhinitis are generally perceived as being effective,1 but about 20% of patients are not satisfied with their treatment.
Conventional Treatment of Allergies
The basic principles in the treatment of common allergic diseases are allergen avoidance, medications, and allergen immunotherapy.3 Medications include antihistamines, decongestants, mast cell stabilizers, and topical corticosteroids.4 These medications are typically effective, but they are associated with side effects such as sedation, rebound nasal congestion, and even septal perforation.4 Thus, effective treatments that do not have significant side effects would be desirable. The use of complementary and alternative medicine (CAM) in patients with allergies is very common; up to one-half of patients with asthma or rhinosinusitis have tried CAM therapies.5
Epidemiology of CAM Usage for Allergies
Usage of acupuncture and other complementary and alternative therapies for allergic disorders has been reviewed by Schafer.6 Roughly half of asthmatics in the United Kingdom have used CAM, with the most popular modalities being breathing techniques, homeopathy, herbalism, and acupuncture. In Italy, of 970 outpatients of allergy clinics, 33% of patients reported using CAM, with homeopathy, herbalism, and acupuncture being most popular. In Germany, 26% of allergy patients reported using CAM, with most using only one modality.6 Most of the CAM usage fell into one of four types: homeopathy, autologous blood injection, acupuncture, and bioresonance (autologous blood injection and bioresonance are not typically used in the United State). The most important sources of information regarding CAM were the physician (40%) and friends and family (37%), with media and non-physician health care practitioners playing a minor role.
Basic Science Research
Limited evidence suggests that acupuncture may play a role in allergic disorders. The anti-inflammatory actions of acupuncture may be mediated via the reflexive central inhibition of the innate immune system.7 Neural modulation of the innate immune system involves both pro-inflammatory and anti-inflammatory actions, with the parasympathetic nervous system playing the leading role in down-regulation of cytokine synthesis and containment of somatic inflammation.7 Acupuncture is thought to affect the cholinergic anti-inflammatory pathway.7 Multiple inflammatory mediators have been reported to be affected with acupuncture, such as neuropeptides, cytokines, and other vasoactive substances.8 For instance, IL-10-dependent T-cells are found in those with allergic diseases, and acupuncture may have anti-inflammatory effects via balancing pro-inflammatory and anti-inflammatory cytokines as discussed in a review article on the anti-inflammatory and immunosuppressive actions of acupuncture.8
A mouse model was used to investigate the impact of electroacupuncture on models of anaphylaxis and inflammation.9 Mice were randomly divided to receive either electroacupuncture (true vs. sham) or to a control condition. The control condition was used to normalize stress across groups, and involved being kept in an acrylic holder for 10 minutes. Electroacupuncture was done at either Stomach 36, or at a sham point, which was a non-acupuncture point lateral to Stomach 36. Multiple outcomes were assessed. Acupuncture did not significantly affect ear swelling in response to administration of an intradermal allergenic compound. Electroacupuncture inhibited the anaphylaxis model, and sham acupuncture had no effect. Electroacupuncture also inhibited mast cell degranulation, and it decreased IL-6 secretion. TNF-a was not significantly affected. This study is limited in that the published manuscript does not fully describe the results of each of the study interventions, true vs. sham, acupuncture vs. control, various electrical frequencies used in stimulation, and duration of stimulation. The authors conclude that the electroacupuncture treatment may have various regulatory effects that explain its potentially beneficial effects in anaphylactic and inflammatory conditions.
In humans with allergic rhinitis, acupuncture has been found to affect gene expression, improving the balance between pro-inflammatory and anti-inflammatory cytokines.10
Clinical Trials
Clinical observation has demonstrated that allergic disorders such as allergic rhinitis can be improved with acupuncture.11 In 2002, Xue et al reported a two-phase crossover, single-blind clinical trial in which 30 subjects were randomized to receive either real or sham acupuncture three times weekly for 4 weeks, and then crossed over to the other treatment.4 No washout period was included. The sham treatment was needling at a point 1.5 cm lateral to the true point. There was a significant improvement noted in subjective symptom scores in real acupuncture relative to sham. Relief medication was not analyzed statistically because only one subject used relief medications during the study. No side effects were reported by any subjects during the course of the study.
More recently, the same investigators conducted a randomized, single-blind, and sham-controlled study.12 Eighty subjects with persistent allergic rhinitis received either sham or real acupuncture twice weekly for 8 weeks, and then were followed for up to 12 additional weeks. After 8 weeks of treatment, nasal symptoms improved from baseline more with real acupuncture than with sham acupuncture (P = 0.01). At the end of the follow-up period, the improvement was maintained; the difference between real and sham acupuncture was highly significant. Both real and sham acupuncture were well tolerated.
Children with persistent allergic rhinitis may also improve with acupuncture.13 Real acupuncture was compared with sham acupuncture in 72 pediatric patients, mean age around 11 years. Patients and their pediatricians were blinded. Daily rhinitis scores were significantly lower in the real acupuncture group, and this effect persisted for the 12-week follow-up period. The relief medication scores were the same in both groups. Visual analog scores for immediate improvement were higher in the real acupuncture group compared to the sham group.
In 2008, a German group also investigated acupuncture for allergic rhinitis in a large trial where the acupuncture was reimbursed by insurance only if subjects participated in the research study.14 Subjects were randomized to receive either up to 15 acupuncture sessions over a 3-month period, in addition to usual care, or to a usual care control condition that did not include acupuncture until after the first 3 months of the study. Those who did not consent to randomization received acupuncture treatment. A total of 981 subjects accepted randomization, and 4,256 did not and thus were included in the nonrandomized acupuncture group. At 3 months, scores on the Rhinitis Quality of Life Questionnaire improved significantly in the acupuncture group relative to the control group, with each of the factors, such as sleep, nasal symptoms, eye symptoms, and activities, each being statistically improved in the acupuncture group. Overall health-related quality of life was also improved in the acupuncture group. While refusal to consent to randomization raises concerns about bias, no differences were found between those who chose randomization vs. those who did not, suggesting lack of a selection bias in the subjects.
In contrast, in a small study with 40 subjects with allergic rhinitis and a positive skin test, no differences were found between true acupuncture and sham acupuncture.15 IgE levels were compared between true and sham acupuncture and, with the exception of one allergen, there were no differences found between groups. It is possible that this study was underpowered, even though this was the largest study published at the time (2004). The authors comment that the sham acupuncture should be considered "weak acupuncture," rather than placebo acupuncture.
Safety
Acupuncture is generally considered to be a safe procedure.16,17 In the large Brinkhaus study with more than 5,000 subjects, roughly 11% of subjects experienced an adverse event. Of these, 69% reported minor local bleeding or hematoma, 9% had needling pain, 4% had local infections at needle insertion site, 2% had vegetative symptoms, and 16% had other adverse events.14 No life-threatening adverse effects were reported. In the pediatric study,13 no serious adverse effect was noted in either group. Lightheadedness and numbness at the insertion site were noted with equal frequency in both the sham and real groups, and these effects were mild and transient.
Conclusion
Based on the above studies, it is possible that acupuncture is a helpful adjunct to usual care for patients with allergic rhinitis. No studies compared acupuncture alone to medication alone, however, and to determine if acupuncture is more effective or better tolerated than medication a comparative study would be required. Acupuncture is generally without serious adverse effects, and it may prove to be a helpful addition to the armamentarium for allergic rhinitis.
References
1. Valovirta E, et al. The voice of the patients: Allergic rhinitis is not a trivial disease. Curr Opin Allergy Clin Immunol 2008;8:1-9.
2. Xue CC, et al. Does acupuncture or Chinese herbal medicine have a role in the treatment of allergic rhinitis? Curr Opin Allergy Clin Immunol 2006;6:175-179.
3. Allergy: Conventional and alternative concepts. Summary of a report of the Royal College of Physicians Committee on Clinical Immunology and Allergy. J Royal College of Physicians of London 1992;26:260-264.
4. Xue CC, et al. Effect of acupuncture in the treatment of seasonal allergic rhinitis: A randomized controlled clinical trial. Am J Chin Med 2002;30:1-11.
5. Man LX. Complementary and alternative medicine for allergic rhinitis. Curr Opin Otolaryngol Head Neck Surg 2009;17:226-231.
6. Schafer T. Epidemiology of complementary alternative medicine for asthma and allergy in Europe and Germany. Ann Allergy Asthma Immunol 2004;93(2 suppl 1):S5-S10.
7. Kavoussi B, Ross B. The neuroimmune basis of anti-inflammatory acupuncture. Integr Cancer Ther 2007;6:251-257.
8. Zijlstra FJ, et al. Anti-inflammatory actions of acupuncture. Mediators Inflamm 2003;12:59-69.
9. Moon P, et al. Use of electroacupuncture at ST36 to inhibit anaphylactic and inflammatory reaction in mice. Neuro-immunomodulation 2007;14:24-31.
10. Shiue HS, et al. DNA microarray analysis of the effect on inflammation in patients treated with acupuncture for allergic rhinitis. J Altern Complement Med 2008;14:689-698.
11. Lai X, et al. Observation on the curative effect of acupuncture on type I allergic diseases. J Tradit Chin Med 1993; 13:243-248.
12. Xue CC, et al. Acupuncture for persistent allergic rhinitis: A randomised, sham-controlled trial. Med J Aust 2007; 187:337-341.
13. Ng D, et al. A double-blind, randomized, placebo-controlled trial of acupuncture for the treatment of childhood persistent allergic rhinitis. Pediatrics 2004;114:1242-1247.
14. Brinkhaus B, et al. Acupuncture in patients with allergic rhinitis: A pragmatic randomized trial. Ann Allergy Asthma Immunol 2008;101:535-543.
15. Magnusson A, et al. The effect of acupuncture on allergic rhinitis: A randomized controlled clinical trial. Am J Chin Med 2004;32:105-115.
16. MacPherson H, et al. The York acupuncture safety study: Prospective survey of 34000 treatments by traditional acupuncturists. BMJ 2001;323:486-487.
17. White A, et al. Adverse events following acupuncture: Prospective survey of 32000 consultations with doctors and physiotherapists. BMJ 2001;323:485-486.
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