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Wise et al.

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• Intervention: Combination therapy with INCS and intranasal antihistamine may be used as second-line therapy in the treatment of AR when initial monotherapy with either INCS or antihistamine does not provide adequate control. IX.B.11. Nontraditional and alternative therapies IX.B.11.a. Acupuncture.: In complimentary medicine, acupuncture has the distinction of being 1 of the oldest forms of healing arts practiced, with its origins dating back to the 6th to 5th centuries BC. 1498 Traditional Chinese medicine holds to the concept that the body’s vital energy (Qi) flows through a network of meridians beneath the skin. 1499 In a healthy state, the flow of the Qi is uninterrupted whereas disease states mark a disruption of the Qi. The aim of acupuncture is to stimulate acupuncture points (acupoints) with needles to recover equilibrium. Acupoints are specific anatomic points located along meridians that are believed to correspond to the flow of energy through the body. There have been several blinded RCTs evaluating acupuncture as a treatment for AR. Acupuncture has an excellent safety profile with only minor side effects reported. 1500,1501 Some studies have shown acupuncture to influence allergic and inflammatory mediators including IgE and IL-10 levels in AR patients significantly more than controls, 1501,1502 suggesting a possible immunomodulatory effect. The clinical significance of these changes, however, remains to be seen. Two meta-analyses addressing acupuncture have been performed (Table IX.B.11.a). The first, published in 2008 reviewed 7 RCTs and found a high degree of heterogeneity between studies with most studies being of low quality. 1500 No overall effects of acupuncture on AR symptom scores or use of relief medications were identified. 1500 A more recent meta analysis of 13 studies had more favorable findings, demonstrating a significant reduction in nasal symptoms, improvement in RQLQ scores, and decreased use of rescue medications in the group receiving acupuncture. 1501 This meta-analysis included 6 of the 7 studies in the 2008 review and 7 new studies. Again, a high level of heterogeneity between studies and varied quality of the studies was noted. Most important to note is that neither meta-analysis discussed the specific consideration of concomitant AR medication use during the trials, which is common in most acupuncture trials. The uncontrolled use of AR medications could have significantly impacted the outcomes in any of these studies and raises concerns when interpreting the results. • Aggregate Grade of Evidence: B (Level 1a: 2 studies; Level 2b: 13 studies; Table IX.B.11.a). Only level 1a studies are presented in the table. • Benefit: Unclear, as 1 meta-analysis showed no overall effects of acupuncture on AR symptoms or need for rescue medications and a second meta-analysis showed an effect of acupuncture on symptoms, QOL, and need for rescue medications. • Harm: Needle sticks associated with minor adverse events including skin irritation, pruritis, erythema, subcutaneous hemorrhage, infection, and headache. Need for multiple treatments and possible ongoing treatment to maintain any benefit gained.

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Int Forum Allergy Rhinol . Author manuscript; available in PMC 2020 June 10.