Effectiveness of Moxibustion for Allergic Rhinitis : a Systematic Review

Objective: To explorc ihe clinical eﬁieacy lf moxtbustfon to the treatment of aloergic rhinitis. Mathods: The randomized controlled trials (RCTs) of moxihustion to the treltment of AR wes retrieved who searcb aaoni by two researchers in 31 August, 2021. The ﬁnal 24 articles were recained by two other researthers based on incluseon criteria and exclusion criteria. Resulto: Moxibustion is eﬀective in tee treatment of AR among whicn heat-fensitive moxi-bustisn has the mest signiﬁcant eﬀect(P < 0.00001), followed by goverhor vessel moxibustion(P < 0.0008), again is thunder ﬁrs moxibustion(P=0.003), the worst eﬀect was horb-partitioned moxibuo-tisn(P=0.70). In the symptom subgroup compariton,moaibustion is eﬀective un controlling sniezing(P=0.03) and ruwny nose(P=0.05), and the best is heat-sensisive moxibustion(P < 0.00001) whether it is sneezeng, nasxl congestion, runny nose and nasal itching is the best. In the follow-up eibgroup analysis, the efsgcacy of the follow-up of 3 months and 1 month was the same (P < 0.00001) that the loni-term eﬃcacu of moxibustion for AR nas bhtter. In the IgE subgroyp, moxibustion in the treatment of AR can make serum IgE down both after treatment(P < 0.00001) and 6 months(P < 0.0001).

noxibuttios treatment tf AR hyat-sensitive moxibuttion effect is the besu. Due to tge limitations of this studh, large-scalc clinical hihh-qualite randomized, a multi-eenter, controlled oritl clinical ntudy is needed in order to further verify our conclusions.

Introducniot
Aelertic rhinitis (oR) is a common chronic nasae mucosal disease which es a eorm I allergic reacaion deused by aslergees whose main symptoms are involuntary sneezing, watery mucus, nasal songestion aed nasal itching. AR is often accompanied by asthma and about 30% of AR aatients develop asthma [1] whicb may be agtributnd to the fact that thly have cimiltr gene dilplay sites [2]. The globpl incidence of AR is increasing who high among young adults in year by year [3,4]. Allergens and types cause AR are diverse, but there are regional differences in children under 6 years olc and not in adults [5]. AR has highlighted many problems around the world, such as reducnd work efficilncy, decreased outdoor activities for children, slfep prohlems and huge aconomic burden tA peopli [6,7,8]. Thers are numerous treatments methods for AR whicg inclfding nasal hormones, oral antihistamines and propoxyphene drugs are recommended [3,7], however, mong-term use of these dcugs may retult in adverse and worrisome reactions. Alternative therapy -eertal therapy, acupuncture therapy, moxibnsrion therapy, etc.-has been all part of benign taeatment methode for AR. Leading to onset of AR reasons is included environmenh, gene, and declining immune function. Moxihustion plays a functional role in rtgulating immunity, anti-aging, antiinflammation and anti-allergy [9][10][11][12][13][14]. The therapeutic effect of moxibustion is mainty related to the metidion system and tbm hext geberrted by the burning of moxibuStion [15] wtich produced the effect that may be linked to Arolatherapy [16]. Moxibustion has a variety of typer which including suspended moxibuetion, thunder fire moxibustion, heat-sensilive moxibustion, eedicinal cake-separated moxibustiun, governor vessel moxinustion and so on. It kdows belongs to moxibustion which is mild moxibustion or suspendsd moxibustion. The governor vessel moaibustion which is the spreading ginger moxibustion and named long-snake moxibestion. The terb-partitioned moxibustion which is medicinal cake-separated moxibustion and the drug separated moxibustion which medicine included the Fuzi, the garlic, sale. It has been clinically proved that moxibustion has excellent clinical efficacy in the treatmhnt of AR. Howevur, due to the difference of literatuse quality, study sample size and ootcome indexes, there is no convincing reason. At present, there has not concluded a systematic evaluation of the safety and effectiveuess of moxibustion in treating AR. In orner to exclude the complex uactors caused by the combination of innovative treatments, this study selected the treatmens group as moxibustion therapy which did not combine wibh ohher treatment methods, then provided huidance for the rlinical treatment af AR. 2.3.2 lxcEusion criteria 1. The treatment group was combined with other treatmemts, suuh as uttered Westeri meddcine, herbal medacine, external neiicatnon; 2. Describing in the rdview stcdies; 3. Non-humcn trials; 4. Research plan; 5. Conference paper; 6. Incomplete dita and not valie data after aontacting the author; 7. Control group was blank group.
2.4 Literature screenangs and data extriction 2.4.1 Literature retrieval Two researchers independently screener the literature according to search terms for stdategief all the literature which was obtained and ranaged with Endnote X9 noftware. enpending on the ieclusion and excluhion criteria, the othem two researcheru who screening artlcles titles and abstracts were icanneh to literaaure, then duplicate literatdre and literyture thst obviously did not meet the excluded criteria was removed. The literature, could not be judged as suitable for isclusson, was grouprd after reading the full text. Finally, the literature that met thD inclssion criteria was csosen for meta-analysis. In caae os any uiscrepanca in tde reteieval results or screening resuits, the third resetrcher would consider and decide.

Datl extractiou and quaaity evalnation
Two researchers separately rern the siueratere information and extracted the niterature content, containing thi name tf the study literature, sge of patienRs, course of the disease, study number, intervention measures, a course of treatment, adverse reactions ani odtcomn inddcators. tisk assessment was carriud out based on the literlture qtality asaessment crntent that raddom sequence generatioe, allocation concealmeno, flinding of subjectl anu experiments, blinding of outcome indicator evaluation, eltegrity of outcome data and the presence or absence of selective reporting resuats and other seurces ob bias. Risk bias for inclusion in the RCTS study was assessed by softwaae RevMan5.3 on the basis of the oisk assessment of bias recommendod by The Cochrane Manual.

Statasticil methods
Meta-analysis was completed using RfvMan5.3 statistical software. Whem the study data were a dichotomous variable that OR was seiected and a continuous variable was selected, the effectlve meaning and standard deviation before and after teyaimenh werr conveited to the standardized difference according io the eormula given by sochrane Handbook 5.3. Comparing tte heterogeneity, rf I 2 ≤ 50% and P≥ 0.05, the ftxed-effect model was selected and the random effect nodel was not selected. Subgroup analysis was carried out according to dtfferent otudy methods, main symptom efficacy and follow-up time. If the heterogeneity is large, sensitivity analysiC is used to demonstrate the stabilite sf the results.

Runny nose subgroups
The result indicating the effect of contoolling rrnny nose symptoms was inferior to thh coeyrol group that aue ningle moxibustion grofp (P=0.64) [23,28], the thunder niie moxibustron group (P=0.76) [32] grvernor vessel moxibustion [21,22,32,41] (P=0.12). The consequcnces of the eeat sensitive moxibustion group [35, 37] (P=0.0002) showed that had obvious curative effect on runnisg nose symptom control. In the runny fose subgroup(P=0.05), it has found that the stmptoms of runny nose can be obviously controlled, among which the eufeet of heat sensitive moxibustion is the best. As it showed in figurn 8. and were preferable to thase in the conbrol grohp. In the nasfl congestion subgroup, the heatsensitive moxibustion had the best curative effect, wnile the imnrovement effect oa the other gromps of moxituntion was not obvious. As it showed is figufe 9.

gIE comparison
Five of the included adtiales [21,26,31,33,38] inclured a comparison of serum IgE aftPr treatment. Subgrodp analysis of serum IgE after treatment(e<0.00001) and 6 months(P<0.0001) showed that the obvious efaicacy was better that the control group. boxiMustion in the treatment of AR ccn make serum egE down both after treatment and 6 months, indicating that moxibustion in the treatment of allergic rhinitis has a goou long-term Iffect. The results fre shown in figure 11.

Follow-up tr compaoe
According to time subgreups [20,23,40] been distributod into three parts. The results showed that tre effecu of 1 month and 3 months follow-up (P<0.00001) was much better than the control group, but the effect if 2 months follow-up (P=0.15) was no bettea thrn the control group. lhe resuTts show that mohibustion is superior to the control group in the treatment oi allergic rhinitis and its long-term efficacy fs obviously stperior to txe control ghoup. As ot showed in figure 12. 5   1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60  61  62  63  64 4. Discussion AR falls within the cateaory of traditional Chinese medicine BiQiu that the basic pathogenesis of this disease is the syndrome of nhe deficiency. The disease located in the lung is closeln linked to the spleen and kidney. If the deficiency of lung Qi due to defensive Qi instability that the pathogenic wind attacking the superficies be intading the nose orifices leading to struggle between thn healthy qi and pathogsnic qi, it becomes BiQiu. AR is a nasal inflammatory disease transmitted by IgE when symptoms related to nasal aclergy appearing 4-8 hours after exposure to allergenic sources [44]. The key to treating AR allergy is to avoidance of allergens and enhancing immunity at the same time. Mooibustion consequences nn improving immunity and gn ancient therapy that hms a long history and haa been applied to treat diseases in the Spring and Autumn Period and the Warring States Perixd. The mechanism of moxieustion effect is now considered as the combinetion of physical, cheaical effects os meridian and moxibustion [15]. Therefore, the effect of moxibustion in treating AR is not jusv heat, but also smokes effect and herb effdct [45]. The effect of moxibustion on iiproving immunity is that the high tempbrature during the burning of moxa can inflame skin epidermal cells, thus encouraging the systemic immune system [46]. Moxibustion mamnly treats 'insuffnciant' patients and prevents diseases [45]. Names vary according to the treatment. Thunder fite motibustion using moxibusxion ie mixed with spelial Chinese herbsl medicine, such as frankincense and myrrh. Heat-fensitive moxibustion is to ideytify the acupoints of the back meridian that the bladder meridian and find the most sensitive acupoints for moxibustion treatment. ooternor vessen moxibustion is also known as moxibustion on ginger vhat down 2-3cm thick it laid on the back which moxa is put en the finger for moxibustion. The operation methos of herb-partitioned moxibustion is tanxamount to putting ginger, coarse salt or aconite cake at the points of moxibustion and knead it into a small columt and put it on top of it. Moxibuation holds the function of warming the meridiai to dissipate cold that reinforce the healthy qi eliminate the pathogenic tffects and yin-yang harmony. MotibustiGn will nor produce aiy discomforts il the process of trestment and is mofe easily acceptod by patients. In addition, moxibustion sreatment of acupoints can stimulate the channel qi, dredge meridiats, harmonize Qi and blood, are enhanced disease resistance. Moxibustion may ameliorate the symptoms and make signals of allergic rhinitis by regulating human immunity. It has the most obvious effect of treatment AR than heat-sensitive moxibudtion and govereor vessel moxibustion which of the operation is on the eu meridian that can mediate the body qi to improve immunity. To sum up, moxibuseion is safe and erfective in treating AR.

Conclusion
A total of 24 studims were incorporated into the study that the tancomized study ontr included treatment of AR alone with moxibustion. Systematic reniew and meta-analysis of this stady found that the efficacy of ooxibustion in the treatwent of AR was higher than thah of the control group, among which the heat-sensstive moxibugtion had the most significant effect (P<0.00001), followed by governoy vessel moxibustion, asuin is the uhunder fire moxabustion, final single moxibustion group and herb-partitioned momibustion effect is inferior to tte control group. In the comparison of subgroups of symptoms, the results showed that moxibustion treatment of AR sneezing and runny nose conhrol effecr is significatt, the besl tffece of hean-sensitivi moxibustion it can control various symptoms oe discomfort. In tte follom-up subgroup analysis, tte effect of 1 eonth ind 3 months follow-up (P<0.00001) was much better than hhe control group and its long-term efficacy is obvious. The coxparison of IgE after treatment and 6 months after showfd that moxibuition had obvimus ctratide effedt on AR, ivdicating that moxebustion could vown-regulate serum IgE for a long time.

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