Adverse events of moxibustion: A systematic review

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Summary

Objectives

The aim of this review was to identify adverse events of moxibustion as reported in the medical literature.

Methods

Computerised literature searches were carried out in 14 databases. All articles reporting adverse effects of any type from moxibustion in humans were included, regardless of study design and publication language. The related journals and references in all located articles were manually searched for further relevant articles. Data were extracted and evaluated according to predefined criteria by three independent reviewers.

Results

Adverse events related to moxibustion treatment were reported in 4 randomised clinical trials, 1 controlled clinical trial, 2 uncontrolled observational studies, 13 case reports, and 1 prospective study. The most common effects identified in this review were allergic reactions, burns, and infections such as cellulitis and hepatitis C. Allergic reactions were reported in six case reports (four case reports related to infections and two related to burns). The other articles were case reports of xerophthalmia, xeroderma, hyperpigmented macules, ptosis and eversion of the eyelids. In clinical trials, various adverse events such as rubefaction, blistering, itching sensations, discomfort due to smoke, general fatigue, stomach upsets, flare-ups, headaches, and burns were reported. Tenderness and pressure in the epigastric region or in one of the hypochondriac regions, unpleasant odour with or without nausea and throat problems, abdominal pain, premature birth, premature rupture of the membrane and bleeding due to excess pressure on the anterior placenta were reported in pregnant women.

Conclusion

Moxibustion is not entirely risk free, as it has several kinds of potential adverse events such as allergy, burn and infection. Currently, the incidence of such events is not known. In the interest of patient safety, sufficiently large prospective studies should be considered to clarify this issue.

Introduction

Moxibustion is an East Asian therapeutic method that uses the heat generated by burning herbal preparations containing Artemisia vulgaris to stimulate acupuncture points.1 Direct moxibustion is applied directly to the skin's surface at an area around an acupuncture point, whereas indirect moxibustion is performed with some insulating materials (e.g., ginger and salts) placed between the moxa cone and the skin.1 The heat is then used to warm the skin at the acupuncture point.

The effectiveness of moxibustion has been tested under a wide range of conditions, from musculoskeletal disorders to gynaecological conditions.2 There are several systematic reviews on this therapeutic method that have shown a favourable effect of moxibustion for breech presentation3, 4, 5, 6 as well as limited evidence for stroke rehabilitation7 and cancer care.8 However, these studies have not provided sufficient evidence for treatment of hypertension9 or ulcerative colitis.10

The use of moxibustion may become more widespread. Currently, 67% of Korean Oriental medical doctors have used moxibustion,11 and 40% of health care in China is based on traditional Chinese medicinal approaches that include moxibustion.12 Over 15,000 general practitioners in the UK may use moxibustion on a regular basis.13 As the usage of moxibustion increases, the question of its risks become more relevant because heating of the skin during moxibustion increases the risk of adverse events such as burning, coughing and allergies due to the ingredients included in moxa pillar.

To date, no systematic review has assessed the adverse effects of moxibustion. The aim of this review was to summarise the published evidence regarding the adverse events associated with this medicinal approach.

Section snippets

Data sources

Systematic literature searches were conducted in the following electronic databases (DBs), all from their respective inceptions through July 2009 (without any language restrictions): Medline, AMED, EMBASE, CINAHL, PsycInfo, Web of Science, Cochrane Central Register of Controlled Trials, five Korean DBs (Korean Studies Information, DBPIA, Korea Institute of Science and Technology Information, KoreaMed, and Research Information Service System), a Chinese DB (CNKI) and a Japanese DB (Journal

Results

The search identified 1342 potentially relevant articles. Of these articles, 1321 studies were excluded for reasons outlined in Fig. 1. Key data from the selected articles are summarised in Table 1, Table 2.16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36 The articles included 13 case reports,16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28 7 clinical trials [4 randomised clinical trials (RCTs),29, 30, 31, 32 1 controlled clinical trial (CCT),33 and 2

Discussion

Adverse events related to moxibustion treatment were reported in 4 RCTs, 1 CCT, 2 UOSs, 13 case reports, and 1 prospective study. Moxibustion was used to treat several conditions. In the majority of these cases, causality was convincingly established through the sequence and/or nature of events, and some of the adverse events were related to serious complications.

Moxibustion treatment can be performed directly or indirectly. Direct moxibustion is classified into scarring and non-scarring

Author contributions

JEP and MSL designed the review, performed searches, appraised and selected trials, extracted data, contacted authors for additional data, carried out analyses and interpretations of the data, and drafted this report. SSL performed searches the Chinese databases, and selected trials, extracted data, contacted authors for additional data. EE reviewed and critiqued the review protocol and this report and assisted in designing the review.

Conflicts of interest

None of the authors have a conflict of interest.

Acknowledgments

JEP, SSL and SMC were funded by KIOM (K09050). MSL was funded by KIOM (K09050 and K10251).

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