Treatment Recommendations in Korea for Patients with Axial Spondyloarthritis: The Evidence for Acupuncture Treatment in Axial Spondyloarthritis Patients Should be Re-evaluated

Tae-Hun Kim; Myeong Soo Lee; Hyangsook Lee; Stephen Birch; Terje Alraek

doi:10.56986/pim.2024.02.009

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Letter Treatment Recommendations in Korea for Patients with Axial Spondyloarthritis: The Evidence for Acupuncture Treatment in Axial Spondyloarthritis Patients Should be Re-evaluated: Tae-Hun Kim^1,*, Myeong Soo Lee², Hyangsook Lee³, Stephen Birch⁴, Terje Alraek^4,5; Perspectives on Integrative Medicine 2024;3(1):61-62.
DOI: https://doi.org/10.56986/pim.2024.02.009
Published online: February 22, 2024

¹Korean Medicine Clinical Trial Center, Korean Medicine Hospital, Kyung Hee University, Seoul, Republic of Korea

²Division of Clinical Medicine, Korea Institute of Oriental Medicine, Daejeon, Republic of Korea

³Acupuncture and Meridian Science Research Center, Kyung Hee University, Seoul, Republic of Korea

⁴School of Health Sciences, Kristiania University College, Oslo, Norway

⁵Department of Community Medicine, Faculty of Medicine, National Research Center in Complementary and Alternative Medicine, UiT, The Arctic University of Norway, Tromso, Norway

*Corresponding author: Tae-Hun Kim, Korean Medicine Clinical Trial Center, Kyung Hee University, Korean Medicine Hospital, 23, Kyungheedae-ro, Dongdaemun-gu, Seoul 02447, Republic of Korea, Email: rockandmineral@gmail.com

• Received: December 6, 2023 • Revised: January 9, 2024 • Accepted: January 10, 2024

This is an open access article under the CC BY-NC license (http://creativecommons.org/licenses/by-nc/4.0/).

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Axial spondyloarthritis (AxSpA) is a severe chronic inflammatory condition that needs lifelong treatment and management. Due to the unmet needs of patients regarding pain control and symptom management, as well as the negative perception or dissatisfaction with pharmacological treatments offered through Western medicine, many patients with AxSpA have sought complementary medicine (CM) treatments [1]. Considering this, clinicians should be appropriately informed (from reports which are unbiased) not only about the patients’ preferences and needs, but also be informed about the effectiveness and safety of commonly sought CM treatments and modalities. In this sense, including CM such as spa treatments and acupuncture (which are commonly used by AxSpA patients), in the Clinical Practice Guidelines (CPG) in Korea is commendable [2]. However, there are several concerns raised regarding the CPG recommendation in 2023 against the use of acupuncture for the management of the symptoms of AxSpA [2].

Firstly, it is necessary to question whether sufficient literature (relevant to the clinical questions of the CPG) and clinical studies were located for a fair evaluation of the current evidence. It would be more transparent if the databases used and search strategies employed were identified (with respect to acupuncture treatment), in addition to stating whether or not experts in the field of CM participated in the search to retrieve articles. Considering that there is clinical evidence of acupuncture treatment for this condition which indicates that acupuncture may be effective in reducing pain and improving related symptoms in ankylosing spondylitis patients, it is crucial to ascertain whether an appropriate evaluation of the current evidence and synthesis of data was performed to derive the recommendation not to treat AxSpA patients with acupuncture [2,3]. A number of government health advisory groups from around the world including Canada and Australia, and patient advisory groups from New Zealand, Australia, Canada, and the UK have recommended acupuncture as a treatment option for pain control in AxSpA [3–9]. These recommendations are made in part on ankylosing spondylitis-specific evidence but more commonly based on broader evidence for acupuncture in joint pain and chronic pain. In this sense, an extensive literature search may have provided more opportunities to locate relevant studies, which may have affected the strength and direction of the recommendation for the use of acupuncture treatment for AxSpA [4].

Secondly, it does not seem acceptable for the CPG to recommend against the use of acupuncture for AxSpA patients, based on the predefined clinical questions which do not sufficiently retrieve the relevant studies from the literature that support the use of acupuncture. Although not exactly the same, in the UK’s National Institute for Health and Care Excellence (NICE) guidelines for the management of symptoms of axial and peripheral spondyloarthritis in individuals > 16 years, the judgment of effectiveness and cost-effectiveness of acupuncture for the management of symptoms was deferred by the guideline development group and randomized controlled trials were recommended [10]. Although there are cultural differences between the UK and Korea, an open stance with a deferred recommendation should be maintained until there is more evidence, as opposed to a rigid stance and a recommendation made against acupuncture for AxSpA. The guidelines were formed based upon 1 clinical trial when more literature is available that supports the use of acupuncture in pain management. Current research suggests that acupuncture appears to be effective in overall clinical improvement and symptoms related to AxSpA without serious adverse events. This includes not only measures like the Visual Analogue Scale (VAS) for pain, but also a wide range of improvements in indicators such as the Bath Ankylosing Spondylitis Functional Index, the Bath Ankylosing Spondylitis Disease Activity Index, and the Assessment of SpondyloArthritis International Society, which assess the function and activity of the disease in patients with related conditions [11–13].

Thirdly, the inclusion of experts in the development committee would have been beneficial when considering the recommendations for acupuncture treatment of AxSpA. Following the current academic trend of recommending the involvement of multidisciplinary stakeholders in the development of guidelines, it would have been more appropriate that Korean Medicine Doctors who specialized in acupuncture were included amongst the guideline developers or in the Delphi process during development of the CPG [14]. In addition to scientific evidence, the voice of patient focus groups or citizen needs should be considered for the coproduction of implementable CPGs. The specific medical context in Korea as to why patients with AxSpA seek acupuncture treatment should have been considered. We hope the future updates of this guideline will adequately consider the points mentioned in this article to enable a more evidence-based and practice-informing guideline for acupuncture treatment of AxSpA.

Acknowledgments

Concerns raised in this article were submitted in the form of a letter to the journals where the CPG recommendation was issued, but unfortunately was rejected for publication. It is regrettable that these journals have made a decision that appears academically closed-off, limiting the opportunity for counterarguments or open discussion.

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Author Contributions

Conceptualization, writing - original draft, and writing - review & editing: THK, MSL, HL, SB, and TA.

Conflicts of Interest

MS Lee, S Birch and T Alraek are editorial board members of Perspectives on Integrative Medicine but this had no influence in the decision to publish this article. No other potential conflict of interest relevant to this article was reported.

Funding

None.

Ethical Statement

This article did not include any personal information and general research ethics guidelines were followed.

Data Availability

There is no usable data in this article.

References

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[2] Seo MR, Yeo J, Park JW, Lee Y-A, Lee JH, Kang EH, et al. Korean treatment recommendations for patients with axial spondyloarthritis. J Rheum Dis 2023;30(3):151−69.Article PubMed PMC
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[4] Ankylosing spondylitis [Internet]: [cited 2024 Jan 22]. Available from: https://healthywa.wa.gov.au/Articles/A_E/Ankylosing-spondylitis
[5] Arthritis Australia [Internet]: [cited 2024 Jan 22]. Available from: https://arthritisaustralia.com.au
[6] Southern Cross [Internet]: [cited 2024 Jan 22]. Available from: https://www.southerncross.co.nz
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[8] Versus Arthritis [Internet]: [cited 2024 Jan 22]. Available from: https://versusarthritis.org
[9] Arthritis Society Canada [Internet]: [cited 2024 Jan 22]. Available from: https://arthritis.ca
[10] Spondyloarthritis in over 16s: diagnosis and management. diagnosis and management. London (UK), National Institute for Health and Care Excellence (NICE), 2017, Jun;NICE Guideline 65.
[11] Gu C, Li Y. Overview of research on the treatment of ankylosing spondylitis in Chinese medicine. J Biosci Med 2023;11(3):147−55.Article PDF
[12] Xuan Y, Huang H, Huang Y, Liu D, Hu X, Geng L. The efficacy and safety of simple-needling therapy for treating ankylosing spondylitis: A systematic review and meta-analysis of randomized controlled trials. Evid Based Complementary Alternat Med 2020;2020:4276380. Article PubMed PMC PDF
[13] Yu J, Kwon Y-S, Kim H-J, Park J, Kim G-B, Lee H-W, et al. Acupuncture treatment for ankylosing spondylitis using China national knowledge infrastructure: a literature review. J Korean Med Rehabil 2020;30(4):79−88.Article
[14] Qaseem A, Forland F, Macbeth F, Ollenschläger G, Phillips S, van der Wees P, et al. Guidelines international network: toward international standards for clinical practice guidelines. Ann Intern Med 2012;156(7):525−31.Article PubMed

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Treatment Recommendations in Korea for Patients with Axial Spondyloarthritis: The Evidence for Acupuncture Treatment in Axial Spondyloarthritis Patients Should be Re-evaluated

Perspect Integr Med. 2024;3(1):61-62. Published online February 22, 2024

DOI: https://doi.org/10.56986/pim.2024.02.009

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Treatment Recommendations in Korea for Patients with Axial Spondyloarthritis: The Evidence for Acupuncture Treatment in Axial Spondyloarthritis Patients Should be Re-evaluated