Treatment Recommendations in Korea for Patients with Axial Spondyloarthritis: The Evidence for Acupuncture Treatment in Axial Spondyloarthritis Patients Should be Re-evaluated
Article information
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.
Acknowledgements
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.
Notes
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.