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Allergic rhinitis

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Translation - Evidence Based Acupuncture Evidence Summary - Acupuncture for Allergic Rhinitis

Worldwide, about 10 to 30% of the population experiences symptoms of allergic rhinitis, and in some countries, the prevalence is as high as 54% [1], [2]. Allergic rhinitis occurs in all age groups but is most common in children. It affects men and women equally [3].
Allergic rhinitis can occur both seasonally and throughout the year. Typical seasonal triggers are pollen. Persistent symptoms are often caused by pet hair and dander as well as dust mites. Allergic rhinitis causes sneezing, a runny nose, itchy nose (and sometimes eyes), a blocked nose leading to disrupted sleep, fatigue, and reduced concentration. It has a significant negative impact on quality of life and work performance. Research in Sweden indicates an annual productivity loss of over 2.5 trillion dollars [4].

People with allergic rhinitis often also suffer from other allergic conditions such as asthma and skin complaints. The close relationship between the nose, lungs, and skin was already described in a text more than two thousand years old, The Yellow Emperor’s Classic of Internal Medicine [5].

This observation corresponds with the modern biomedical perspective that the nose, lungs, and skin are lined with a form of epithelial tissue.

Acupuncture in the treatment of allergic rhinitis
According to the most recent evidence, acupuncture is an effective treatment for allergic rhinitis. Studies also seem to indicate that acupuncture is safer than the currently commonly used medication and may also be more cost-effective [6],[7].

Allergic rhinitis

In 2017, the research project The Acupuncture Evidence Project by Dr. John McDonald PhD and Dr. Stephen Janz was published. This research project consists of a comparative review of clinical and scientific evidence for acupuncture [8]. This includes two systematic reviews, two randomized controlled studies, a clinical practice guideline for allergic rhinitis, and two studies on cost-effectiveness. The reported evidence of effectiveness and efficacy of acupuncture for allergic rhinitis was of average to high quality [9], [10], [11], [12], [13]. Symptoms that showed the greatest improvement were sneezing, itchy nose and eyes, runny nose, blocked nose, and interrupted sleep [12].

Another review, which included studies both before and after the above review, included 12 randomized controlled studies with 12 to 30 treatments and a frequency of 2 to 5 treatments per week. In all 12 studies, 'real' acupuncture was significantly more effective than 'fake' acupuncture (8 studies) and medication (4 studies) [12-23].

Symptoms continued to improve up to 3 months after treatment. Studies that measured changes in the immune system also reported significant reductions in inflammatory factors, including the neuropeptide Substance P (SP), Vasoactive Intestinal Peptide (VIP), Interleukin-4 (IL-4), and dust mite specific IgE [12], [20], [21].
In the United States, acupuncture is recommended in the clinical guideline for allergic rhinitis by the Otolaryngology Head Neck Surgery Foundation as a treatment option for those who prefer a non-pharmacological treatment [24].

Biological mechanisms of action
In people with allergic rhinitis, the immune system considers a number of irritating but harmless substances as a threat (an allergen) and creates a specific immunoglobulin called IgE for it. These IgEs then trigger mast cells in a process known as 'priming'. When these mast cells encounter an allergen, such as pollen, they react by releasing a cocktail of substances (including histamine) that cause inflammatory reactions in the nasal mucosa. 

Once the nasal mucosa is inflamed, the nerve endings in the nasal mucosa also release inflammation-promoting neuroproteins such as Substance P (SP), the CGRP protein, and the Vasoactive Intestinal Peptide (VIP). These neuropeptides exacerbate the inflammatory response and cause itching, sneezing, runny nose, and nasal congestion. The hypersensitive nose then also reacts to a wide range of other irritating substances such as perfume, smoke, and changes in temperature and humidity.

Allergic rhinitis

This allergic inflammatory reaction involves a cascade of interactions between receptors and inflammatory mediators [25]. The main receptors involved in allergic rhinitis are the histamine receptor (targeted by antihistamine medication) and the so-called transient receptor potential V1 (TRPV1) or the vanilloid receptor TRPV1. Activation of the TRPV1 receptor causes an itchy nose and eyes, sneezing, and a runny nose.

Allergic rhinitis

Acupuncture reduces the symptoms of allergic rhinitis and improves tolerance to potential allergens by reducing IgE levels, as well as the expression, sensitivity, and activation of TRPV1 through various neurological pathways [25]. Acupuncture also reduces Substance P (SP) by 77.8% in the first 24 hours after the initial treatment, and Vasoactive Intestinal Peptide (VIP) in allergic rhinitis and the protein CGRP in migraine [12], [21], [26].

The conventional treatment of allergic rhinitis
The conventional treatment of allergic rhinitis advises avoiding triggers and includes oral medication, nasal sprays, and allergen immunotherapy.
For example, people suffering from pollen allergies could remove certain plants from their garden, wear surgical masks to reduce pollen exposure, or even, in some cases, move to a different location. To reduce dust mites, one can purchase hypoallergenic mattresses and pillows, as well as remove carpets and curtains. Pets that cause reactivity in the nasal mucosa should no longer have access to the bedroom and in extreme cases should be relocated. Avoiding triggers can be effective but is not always possible or practical.
Over-the-counter oral antihistamines as well as prescribed oral steroids and mast cell stabilizers are the most commonly used forms of pharmacological therapy. [27] These can be combined with corticosteroid nasal spray to relieve temporary symptoms. Allergen immunotherapy is generally administered as a course of subcutaneous injections over a period of (3-5) years and is now also available as a sublingual tablet [28].
Unlike medication that provides temporary symptomatic relief, allergen immunotherapy (AIT) is considered the only pharmaceutical therapy that alters the course of the disease [29].

Conclusion
Recent research shows that acupuncture is an effective and relatively safe treatment option that can provide both temporary symptomatic relief and lasting benefits up to three months after treatment. In studies, 'real' acupuncture outperformed 'sham' acupuncture, as well as commonly used oral medication. Acupuncture is recommended as a treatment for people with allergic rhinitis who prefer a non-pharmacological treatment [11].

Epilogue
In 2023, a study on acupuncture treatments for nasal congestion due to allergic rhinitis will take place in the Netherlands. The study has been positively assessed by METC Brabant and is being conducted to complete a PhD study in acupuncture at the Nanjing University of Chinese Medicine (NJUCM) in China. In the study, a group of respondents will be treated for 6 weeks with a total of 8 acupuncture treatments according to a fixed treatment protocol with predetermined acupuncture points. The effects of these treatments will be compared with the use of Carelastin© azelastine nasal spray (antihistamine) in the other research group.
Vermeulen, J.M., Acupuncture for Nasal Congestion in Allergic Rhinitis; An Open-Label, Randomized, Monocenter Trail (ANCAR Trial), https://clinicaltrials.gov/ct2...

References:

  • 1. Katelaris CH, Lee BW, Potter PC, Maspero JF, Cingi C, Lopatin A, et al. Prevalence and diversity of allergic rhinitis in regions of the world beyond Europe and North America. Clinical and experimental allergy: Journal of the British Society for Allergy and Clinical Immunology. 2012;42(2):186-207.
    https://pubmed.ncbi.nlm.nih.gov/22092947/ [←]

  • 6. Reinhold T, Brinkhaus B, Willich SN, Witt C. Acupuncture in patients suffering from allergic asthma: is it worth additional costs? J Altern Complement Med. 2014;20(3):169-77. https://pubmed.ncbi.nlm.nih.gov/24256028/ [←]

  • 7. Kim SY, Lee H, Chae Y, Park HJ. A systematic review of cost-effectiveness analyses alongside randomised controlled trials of acupuncture. Acupuncture in medicine: Journal of the British Medical Acupuncture Society. 2012;30(4):273-85.
    https://pubmed.ncbi.nlm.nih.gov/23099289/ [←]

  • 9. Feng S, Han M, Fan Y, Yang G, Liao Z, Liao W, et al. Acupuncture for the treatment of allergic rhinitis: a systematic review and meta-analysis. American journal of rhinology & allergy. 2015;29(1):57-62.
    https://pubmed.ncbi.nlm.nih.gov/25590322/ [←]

  • 12. McDonald JL, Smith PK, Smith CA, Changli Xue C, Golianu B, Cripps AW. Effect of acupuncture on house dust mite specific IgE, substance P, and symptoms in persistent allergic rhinitis. Annals of allergy, asthma & immunology: official publication of the American College of Allergy, Asthma, & Immunology. 2016;116(6):497-505.
    https://www.annallergy.org/article/S1081-1206(16)30126-0/fulltext [←]

  • 13. Xue CC, Zhang AL, Zhang CS, DaCosta C, Story DF, Thien FC. Acupuncture for seasonal allergic rhinitis: a randomized controlled trial. Annals of allergy, asthma & immunology : official publication of the American College of Allergy, Asthma, & Immunology. 2015;115(4):317-24.e1.
    https://www.annallergy.org/article/S1081-1206(15)00342-7/fulltext  [←]

  • 17. Brinkhaus B, Witt CM, Jena S, Liecker B, Wegscheider K, Willich SN. Acupuncture in patients with allergic rhinitis: a pragmatic randomized trial. Annals of allergy, asthma & immunology: official publication of the American College of Allergy, Asthma, & Immunology. 2008;101(5):535-43.
    https://www.annallergy.org/article/S1081-1206(10)60294-3/fulltext  [←]

  • 19. Chen S, Wang J, Bai P, Zhao Q, Tan C, Wang B, et al. [Moderate and severe persistent allergic rhinitis treated with acupuncture: a randomized controlled trial]. Zhongguo zhen jiu = Chinese acupuncture & moxibustion. 2015;35(12):1209-13.
    https://pubmed.ncbi.nlm.nih.gov/29354954  [←]

  • 20. Rao YQ, Han NY. [Therapeutic effect of acupuncture on allergic rhinitis and its effects on immunologic function]. Zhongguo zhen jiu = Chinese acupuncture & moxibustion. 2006;26(8):557-60. https://pubmed.ncbi.nlm.nih.gov/16941973  [←]

  • 21. Li YM, Zhuang LX, Lai XS, Jiang GH. [Effects of electroacupuncture on plasma vasoactive intestinal peptide and substance P in perennial allergic rhinitis patients]. Zhen ci yan jiu = Acupuncture research / [Zhongguo yi xue ke xue yuan Yi xue qing bao yan jiu suo bian ji]. 2007;32(2):136-8. https://pubmed.ncbi.nlm.nih.gov/9388311  [←]

  • 23. Chen Y, Jin X, Yu M, Qiu H, Fang Y, Zhang S, et al. [Efficacy of acupuncture on moderate and severe allergic rhinitis]. Chinese acupuncture & moxibustion. 2015;35(4):339-43. 
    https://pubmed.ncbi.nlm.nih.gov/26054141  [←]

  • 25. McDonald JL, Cripps AW, Smith PK. Mediators, Receptors, and Signalling Pathways in the Anti-Inflammatory and Antihyperalgesic Effects of Acupuncture. Evidence-based complementary and alternative medicine : eCAM. 2015;2015:975632.
    https://pubmed.ncbi.nlm.nih.gov/26339274  [←]

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