Longtao Zhang
Yanxiao Sun2†
Yuxia Ma- 1Acupuncture and Tuina College of Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China
- 2The First Clinical Medical College of Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China
- 3Key Laboratory of Traditional Chinese Medicine Classical Theory, Ministry of Education, Shandong University of Traditional Chinese Medicine, Shandong, Jinan, China
Background: Ulcerative colitis (UC) is a chronic and recurrent inflammatory bowel disease. Current drug treatments are often associated with side effects, unstable efficacy, and high relapse rates. Therefore, exploring complementary and alternative therapies such as acupuncture is of significant importance for optimizing UC clinical management strategies. This study employs a network meta-analysis method to systematically compare the efficacy and safety of various acupuncture-related therapies in treating UC, aiming to provide evidence-based guidance for selecting the optimal clinical intervention.
Methods: We systematically searched 8 databases for randomized controlled trials (RCTs) of acupuncture-related therapies for ulcerative colitis, including China National Knowledge Infrastructure (CNKI), Wanfang Database, VIP Database, China Biological Medicine (CBM), PubMed, EMbase, the Cochrane Library, and Web of Science. The total effective rate, Mayo score, Baron endoscopic score were used for primary outcomes, interleukin-6 (IL-6) levels, tumor necrosis factor-alpha (TNF-α) levels, and relapse rate were selected as secondary outcomes. The Cochrane risk of bias tool (RoB 2.0) was used to assess the quality of the articles, and StataMP 18 was used for statistical analysis. Heterogeneity and consistency were assessed, and the comparative effectiveness of different acupuncture interventions was ranked using Surface under the cumulative ranking curve (SUCRA).
Results: A total of 76 RCTs were included, involving 7,484 participants. Auricular acupressure combined with Chinese herbal medicine (AA + CHM) (RR 1.71, 95% CI: 1.47, 1.99, SUCRA = 99.9%) was shown to have effective to improving total effective rate. For Mayo score, the most effective intervention was acupuncture combination therapy (ACU-CT) (SMD –4.85, 95% CI: –6.66, –3.05, SUCRA = 97.5%). In terms of reducing Baron endoscopic score, ACU-CT (SMD-2.31, 95% CI: –3.81, –0.81, SUCRA = 84.1%) had the best efficacy. For IL-6 levels, warm acupuncture (WA) (SMD –3.10, 95% CI: –4.56, –1.65, SUCRA = 96.1%) showed the best efficacy. For TNF-α levels, warm acupuncture combination therapy (WA-CT) (SMD –2.32, 95% CI: –4.54, –0.10, SUCRA = 76.8%) demonstrated the best efficacy. For recurrence rate, Acupuncture (ACU) (OR 0.15, 95% CI: 0.03, 0.65, SUCRA = 89.3%) achieved the greatest reductions. SUCRA analysis showed that WA, ACU-CT, WA-CT, and acupoint catgut embedding (ACE) ranked highest in most of the outcomes. Acupoint frequency statistics revealed that the most commonly used acupoints for treating UC were Tianshu (ST25), Zusanli (ST36), Shangjuxu (ST37), Zhongwan (CV12), Guanyuan (CV4), Dachangshu (BL25), Pishu (BL20), Shenque (CV8), Qihai (CV6), and Sanyinjiao (SP6).
Conclusion: These findings may provide preliminary evidence-based guidance for acupuncture-related interventions as a potential complementary or alternative treatment for patients with UC, particularly those who have poor responses to conventional pharmaceutical treatment. In the future, more large-sample, high-quality RCTs are needed to further confirm the long-term efficacy and mechanisms of different acupuncture interventions.
Systematic review registration: https://www.crd.york.ac.uk/prospero/, identifier CRD420251082924.
1 Introduction
Ulcerative colitis (UC) is a chronic immune-mediated inflammatory bowel disease (IBD) characterized by persistent inflammation of the colonic and rectal mucosa, often manifests clinically with diarrhea, abdominal pain, bloodymucopurulent, and tenesmus (1, 2). The global prevalence of UC reached 5 million cases in 2023 (2). With changes in the environment, dietary structure, and lifestyle, the incidence and prevalence of UC have been rising annually, particularly in developed countries. With the increasing disease burden, this trend has been extended to traditionally low-incidence regions that are undergoing industrialization (3, 4). Data indicate that UC patients face a 4.5% risk of developing colorectal cancer within 20 years of diagnosis (5), which is 2–3 times higher than that of the general population (6). Furthermore, UC not only causes gastrointestinal symptoms but is also frequently associated with chronic pain, anxiety, and depression, significantly reducing quality of life (7).
Traditional treatments include 5-aminosalicylic acid (5-ASA), corticosteroids, immunomodulators, and biologics (8, 9). While these medications can control inflammation in the short term, they are associated with significant side effects, unstable efficacy, high relapse rates, and drug dependence. For example, 5-ASA may cause gastrointestinal symptoms such as headaches and nausea, and in severe cases, it can lead to interstitial nephritis and other nephrotoxic reactions; Common side effects of corticosteroids include hyperglycemia, osteoporosis, and an increased risk of infection; Immunomodulators are associated with potential adverse effects such as myelosuppression and hepatotoxicity; Biologics carry risks of serious adverse effects, such as serious infections, reactivation of tuberculosis, and lymphoma (10–12). Long-term medication poses safety risks and increases the financial burden on patients. These limitations underscore the pressing need for improved and more effective therapeutic strategies in the management of ulcerative colitis.
Given the limitations of conventional pharmacotherapy, there is a pressing clinical need to explore complementary and alternative treatment options for UC. Acupuncture, a cornerstone of Traditional Chinese Medicine (TCM), was selected for this network meta-analysis for several compelling reasons. First, from a TCM theoretical perspective, the clinical manifestations of UC closely align with syndromes such as “dysentery” and “abdominal pain,” which are traditionally attributed to damp-heat, spleen-kidney deficiency, and qi stagnation. Acupuncture, through stimulation of specific acupoints, is believed to regulate the flow of Qi and Blood, clear damp-heat, and strengthen the spleen and kidney, thereby addressing the fundamental TCM pathological patterns underlying UC.
Furthermore, acupuncture has attracted increasing attention due to its favorable safety profile and multi-target regulatory potential. Clinical studies have shown that acupuncture can alleviate UC symptoms, improve intestinal function, reduce inflammation, and enhance quality of life (13–15). Multiple studies have confirmed that acupuncture therapy can improve the intestinal mucosal microenvironment by modulating the balance of pro-inflammatory and anti-inflammatory factors such as tumor necrosis factor-alpha (TNF-α) and interleukin-6 (IL-6) (16). It can also stimulate specific acupoints to modulate the balance of gut microbiota and regulate gut-brain axis function (17). Furthermore, acupuncture has been shown to inhibit fibrosis and promote epithelial regeneration, as well as to regulate gut microbiota balance (18). Moxibustion can enhance mucosal immune function and promote tissue repair (19). Therefore, a systematic comparison of the relative effectiveness of different acupuncture-related modalities is highly relevant for informing clinical practice and guiding future research.
A diverse range of acupuncture-related therapies is commonly used in clinical practice for UC, primarily including the following modalities: Acupuncture involves the insertion of fine, sterile needles into specific acupoints. Warm acupuncture integrates needle insertion with the burning of moxa on the needle handle to deliver combined needling and thermal stimulation. Electroacupuncture applies a mild electric current through inserted needles to provide continuous stimulation. Moxibustion stimulates acupoints primarily via thermal energy generated by burning moxa (a therapeutic material derived from the dried wool of the mugwort plant, Artemisia argyi), either directly or indirectly atop an insulating medium. Acupoint Catgut Embedding entails the subcutaneous implantation of absorbable sutures at acupoints to provoke a sustained, mild stimulatory effect. Auricular acupressure involves the application of seeds or magnetic beads on specific ear acupoints, which patients are instructed to press periodically for self-stimulation.
However, due to the diversity of acupuncture-related therapies, differing focuses on efficacy, and inconsistent conclusions, previous systematic reviews and meta-analyses (20–23) have only compared single control groups and lack clinical evidence for direct comparisons of efficacy between different acupuncture-related therapies. Therefore, this study employs a network meta-analysis approach to compare the efficacy and safety of various acupuncture-related therapies in the treatment of UC, aiming to provide evidence-based guidance for the use of Traditional Chinese Medicine in treating UC.
2 Methods
The protocol for this systematic review and network meta-analysis has been registered in PROSPERO (CRD420251082924). This study followed the PRISMA 2020 (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and the PRISMA extension statement for network meta-analyses (PRISMA-NMA) (24, 25), as detailed in Supplementary Material 1.
2.1 Search strategy
We searched PubMed, Embase, the Cochrane Library, Web of Science, CBM, CNKI, Wanfang, and VIP databases from inception to June 15, 2025. The search was conducted using a combination of subject headings and free words, and the language was limited to Chinese and English. Search keywords include terms such as “acupuncture, electroacupuncture, warm needling, moxibustion, ulcerative colitis, randomized controlled trials.” Additionally, relevant conference proceedings and clinical trial registries were searched for gray literature. A detailed search strategy is provided in Supplementary Material 2.
2.2 Inclusion and exclusion criteria
2.2.1 Inclusion criteria
(1) S (Study design): Published literature of RCTs, including English and Chinese publications
(2) P (Participants): Patients with a clear diagnosis of UC, regardless of gender, age, and course of the disease. The clinical diagnostic criteria of UC are mainly combined with clinical manifestations, endoscopy, histopathology, and laboratory tests
(3) I (Interventions): The intervention group was composed of various acupuncture-related therapies, including acupuncture (ACU), warm acupuncture (WA), electroacupuncture (EA), moxibustion (MOX), acupoint catgut embedding (ACE), and auricular acupressure (AA). These therapies can be used alone, in combination, or in conjunction with the control group. Combination therapy (CT) included auricular acupressure combined with Chinese herbal medicine (AA + CHM); acupuncture combination therapy (ACU-CT); moxibustion combination therapy (MOX-CT); warm acupuncture combination therapy (WA-CT); acupoint catgut embedding combination therapy (ACE-CT); electroacupuncture combination therapy (EA-CT)
(4) C (Comparators): The interventions in the control group included Western medicine (WM), retention enema (RE), traditional Chinese medicine (CHM) or Western medicine combined with retention enema (WM + RE)
(5) O (Outcomes): Primary outcomes included total effective rate, Mayo score and Baron endoscopic score. Secondary outcomes included IL-6 levels, TNF-α levels, and recurrence rates.
2.2.2 Excluded criteria
(1) Non-randomized controlled trials, such as case reports, observational studies, reviews, or animal experiments
(2) Studies in which patients received multiple concurrent interventions at the same time, such as psychotherapy, cupping, or scraping, or in which the control group also received acupuncture, resulting in the inability to assess the effects of acupuncture independently
(3) Studies that failed to report original outcome data or had unclear efficacy criteria and could not be contacted for further information
(4) Studies with small sample sizes or treatment durations of < 3 weeks.
2.3 Study selection and data extraction
Two researchers independently managed the literature using EndNote 20. The retrieved literatures were first deduplicated, and then titles, abstracts, and full texts were reviewed to select studies that met the inclusion criteria. Disagreements were resolved through consultation or with the assistance of a third researcher. Finally, two researchers cross-checked the literatures. After identifying the eligible studies, data extraction was performed using a pre-designed Excel spreadsheet. The extracted information included: title, first author, year of publication, sample size, age, disease duration, intervention, intervention details, duration of treatment, outcomes, and adverse events.
2.4 Quality assessment
Two researchers independently evaluated the risk of bias using the Cochrane risk of bias tool (RoB 2.0) (26) across five domains: randomization process, deviations from intended interventions, missing outcome data, measurement of the outcome, and selection of the reported results. The results of the assessment were categorized as “low risk,” “some concerns,” or “high risk.” Disagreements were resolved through discussion or by consultation with a third researcher.
2.5 Certainty of evidence
Two researchers assessed the certainty of evidence for the outcomes using the GRADE approach with GRADE pro GDT software (Grading of Recommendations, Assessment, Development and Evaluation) (27). The GRADE system evaluates the quality of evidence based on six domains: Study design, risk of bias, inconsistency, indirectness, imprecision, and publication bias. The overall quality of evidence is classified into four levels: High, moderate, low, and very low.
2.6 Statistical analysis
Network meta-analysis was performed using StataMP 18.0. For dichotomous variables, total effective rate was expressed as the risk ratio (RR), and recurrence rate was represented by the odds ratio (OR). For continuous variables, such as Mayo score, Baron endoscopic score, IL-6, and TNF-α levels, the standardized mean difference (SMD) was used as the Effect size measure, with both expressed with 95% confidence intervals (CIs). A statistically significant difference between groups was considered when the 95% CI for dichotomous variables did not include 1 or for continuous variables did not include 0. Heterogeneity was quantified using τ2, categorized as low (< 0.04), low to moderate (0.04–0.16), moderate to high (0.16–0.36), or high (> 0.36) (28–30). Consistency between direct and indirect comparisons was evaluated using the node splitting method (31). The surface under the cumulative ranking curve (SUCRA) was used to compare the efficacy of different interventions, with a larger area indicating better efficacy of the intervention (32). Funnel plots were used to assess publication bias in the included literatures (33).
3 Results
3.1 Literature search results
A total of 4183 relevant articles were retrieved through database search, 2408 duplicate articles were eliminated by Endnote 20 software, and 286 articles were obtained by reading the titles and abstracts according to the inclusion and exclusion criteria. After reading the full text, 210 articles were excluded. A total of 76 articles were finally determined to meet the inclusion criteria. The literature screening process is shown in Figure 1.
Figure 1. Flow chart of the search for eligible RCTs.
3.2 Included study characteristics
A total of 76 randomized controlled trials were included in this study (13–15, 34–106), with 3,847 cases in the experimental group and 3,637 cases in the control group. The maximum sample size was 220 and the minimum was 60. The age ranged from 30 to 50 years old. The duration of treatment varied from 3 to 6 weeks. The acupuncture point selection schemes differed among the studies, with high-frequency acupoints including Tianshu (ST25), Zusanli (ST36), Shangjuxu (ST37), Zhongwan (CV12), Guanyuan (CV4), and Dachangshu (BL25). Study characteristics are summarized in Tables 1, 2. Both the acupoint frequency statistics and the standardized acupoint definitions are available in Supplementary Material 3.
Table 1. Baseline of characteristics of included studies.
Table 2. Descriptions of the included acupuncture and related therapies.
3.3 Risk of bias, certainty of evidence, and consistency
A total of 76 RCTs were included in this study. 32 studies (42.1%) were rated as high risk of bias due to unclear randomization. 76 studies (100%) did not describe any blinding. Considering the characteristics of the intervention, the risk of bias was judged to be some concerns. 76 studies (100%) had a low risk of missing outcome data and outcome measurement bias. There was no evidence of selective reporting or other potential sources of bias. Overall, 41 studies (57.9%) were rated as some concerns, while 35 studies (42.1%) were rated as high risk. A summary of the risk assessment is provided in Supplementary Material 4 and illustrated in Figure 2. As no closed loops were formed between the included interventions, consistency testing was deemed unnecessary. The consistency model demonstrated good agreement across all comparisons, with no significant inconsistency observed between direct and indirect evidence. Heterogeneity was assessed using τ2, and the results showed low heterogeneity in dichotomous variables, indicating high consistency between studies. For continuous data, there was moderate to high heterogeneity (Supplementary Material 5).
Figure 2. Assessment of risk of bias.
3.4 Network meta-analysis results
3.4.1 Network plots
Among the 76 included RCTs, 75 studies reported total effective rate, involving 10 acupuncture-related therapies; 9 studies reported Mayo score, involving 5 acupuncture-related therapies; 12 studies reported Baron endoscopic score, involving 4 acupuncture-related therapies; 13 studies reported IL-6 levels, involving 5 acupuncture-related therapies; 18 studies reported TNF-α levels, involving 5 acupuncture-related therapies; and 15 studies reported recurrence rate, involving 6 acupuncture-related therapies. Node size reflects the number of participants, while the thickness of the connecting lines represents the number of randomized trials (see Figure 3 and Supplementary Material 6).
Figure 3. Network plot for different interventions. ACU, acupuncture; MOX, moxibustion; WA, warm acupuncture; ACE, acupoint catgut embedding; EA, Electroacupuncture; AA, auricular acupressure; CHM, Chinese Herbal Medicine; RE, retention enema; WM, western medicine; CT, combination therapy.
3.4.2 Total effective rate
The total effective rate was defined as the proportion of patients achieving an “effective” or “improved” outcome. An “effective” outcome required the resolution of symptoms and an essentially normal mucosa on colonoscopy, whereas an “improved” outcome was defined by the presence of intermittent symptoms and only mild inflammatory changes.
This network meta-analysis evaluated the effectiveness of various acupuncture-related interventions in improving clinical symptoms in patients. The results indicated that all ten acupuncture-related interventions significantly improved total effective rate compared with control groups. Among these, AA + CHM (RR 1.71, 95% CI: 1.47, 1.99, SUCRA = 99.9%) showed a relatively greater benefit, followed by ACU (RR 1.37, 95% CI: 1.22, 1.54, SUCRA = 84.8%) and WA (RR 1.34, 95% CI: 1.11, 1.61, SUCRA = 75.1%). Indirect comparisons among acupuncture-related therapies indicated that AA + CHM showed superior efficacy over all other interventions, and ACU was superior to ACU-CT (RR 1.12, 95% CI: 1.01, 1.24), MOX-CT (RR 1.11, 95% CI: 1.00, 1.23), WA-CT (RR 1.13, 95% CI: 1.00, 1.28), and ACE (RR 1.14, 95% CI: 1.02, 1.28) (Table 3). To explore the relative efficacy of each intervention, we calculated SUCRA values (Figure 4; Supplementary Material 7).
Table 3. League table of total effective rate.
Figure 4. SUCRA plot for total effective rate. ACU, acupuncture; MOX, moxibustion; WA, warm acupuncture; ACE, acupoint catgut embedding; EA, Electroacupuncture; AA, auricular acupressure; CHM, Chinese Herbal Medicine; RE, retention enema; WM, western medicine; CT, combination therapy.
3.4.3 Mayo score
Network meta-analysis results based on Mayo score showed that ACU-CT (SMD-4.85, 95% CI: –6.66, –3.05, SUCRA = 97.5%) was associated with the greatest reduction in Mayo score compared with WM, followed by WA (SMD-2.89, 95% CI: –4.68, –1.09, SUCRA = 68.4%), WA-CT (SMD-2.79, 95% CI: –4.57, –1.02, SUCRA = 65.8%), and MOX-CT (SMD-1.82, 95% CI: –2.60, –1.04, SUCRA = 43.7%). Indirect comparisons among five acupuncture-related therapies, ACU-CT was more effective than MOX (SMD-4.14, 95% CI: –6.65, –1.63) and MOX-CT (SMD-3.04, 95% CI: –5.00, –1.07) (Table 4). To explore the relative efficacy of each intervention, we calculated SUCRA values (Figure 5; Supplementary Material 7).
Table 4. League table of Mayo score.
Figure 5. SUCRA plot for Mayo score. ACU, acupuncture; MOX, moxibustion; WA, warm acupuncture; WM, western medicine; CT, combination therapy.
3.4.4 Baron endoscopy score
Network meta-analysis results based on baron endoscopy score indicated that only ACU-CT led to a statistically significant reduction compared with WM (SMD-2.31, 95% CI: –3.81, –0.81, SUCRA = 84.1%). Other interventions showed a downward trend, but without statistical significance (Table 5). To explore the relative efficacy of each intervention, we calculated SUCRA values (Figure 6; Supplementary Material 7).
Table 5. League table of Baron endoscopy score.
Figure 6. SUCRA plot for Baron endoscopy score. ACU, acupuncture; MOX, moxibustion; WA, warm acupuncture; RE, retention enema; WM, western medicine; CT, combination therapy.
3.4.5 IL-6
Network meta-analysis results based on IL-6 showed that among all interventions compared with WM, WA exhibited the most significant reduction (SMD-3.10, 95% CI: –4.56, –1.65, SUCRA = 96.1%), followed by ACE (SMD-2.13, 95% CI: –3.49, –0.77, SUCRA = 77%), WA-CT (SMD-1.76, 95% CI: –2.54, –0.98, SUCRA = 69.2%), and MOX-CT (SMD-1.18, 95% CI: –1.85, –0.50, SUCRA = 49%). Compared with WM + RE, WA (SMD-2.85, 95% CI: –4.71, –0.99, SUCRA = 96.1%), WA-CT (SMD-1.51, 95% CI: –2.90, –0.11, SUCRA = 69.2%), and ACE (SMD-1.88, 95% CI: –3.66, –0.09, SUCRA = 77%) also demonstrated significantly greater reductions. In indirect comparisons, WA was superior to ACU-CT (SMD 2.24, 95% CI: 0.51, 3.98) and MOX-CT (SMD 1.93, 95% CI: 0.32, 3.54). Other comparisons showed a trend of improvement but without statistical significance (Supplementary Material 8). To explore the relative efficacy of each intervention, we calculated SUCRA values (Supplementary Material 7).
3.4.6 TNF-α
The network meta-analysis showed that WA-CT was the most effective intervention in reducing TNF-α levels compared with WM (SMD-2.32, 95% CI: –4.54, –0.10, SUCRA = 76.8%), followed by MOX-CT (SMD-2.00, 95% CI: –3.19, –0.81, SUCRA = 71.7%) and ACU-CT (SMD-1.64, 95% CI: –3.04, –0.24, SUCRA = 61.4%). However, no statistically significant differences were observed among the acupuncture-related interventions (Supplementary Material 8). To explore the relative efficacy of each intervention, we calculated SUCRA values (Supplementary Material 7).
3.4.7 Recurrence rate
For recurrence rate, ACU significantly reduced recurrence compared with WM (OR 0.12, 95% CI: 0.03, 0.43, SUCRA = 89.3%), followed by ACE (OR 0.17, 95% CI: 0.04, 0.77, SUCRA = 78.1%), ACU-CT (OR 0.21, 95% CI: 0.08, 0.57, SUCRA = 76.6%), and MOX-CT (OR 0.21, 95% CI: 0.10, 0.44, SUCRA = 75.4%). Compared with WM + RE, ACU (OR 0.15, 95% CI: 0.03, 0.65, SUCRA = 89.3%) and MOX-CT (OR 0.26, 95% CI: 0.09, 0.76, SUCRA = 75.4%) also showed superior efficacy. Compared with RE, only ACU-CT (OR 0.23, 95% CI: 0.06, 0.84, SUCRA = 76.6%) showed a statistically significant advantage. No significant differences were found among acupuncture-related interventions (Supplementary Material 8). To explore the relative efficacy of each intervention, we calculated SUCRA values (Supplementary Material 7).
3.5 Adverse events
It is worth noting that there were 13 RCTs reported adverse events, involving 125 patients. Among them, 88 adverse events occurred in the control groups and 37 in the treatment groups (Supplementary Material 9). There were no serious adverse effects in any of the studies. The available data suggest that acupuncture-related therapies are associated with a lower incidence and severity of adverse events compared to control group, indicating a potentially better safety profile.
3.6 Publication bias
The potential for publication bias was assessed through visual inspection of funnel plots for all outcomes. The funnel plots for the total effective rate and recurrence rate presented a generally symmetrical appearance, suggesting a low likelihood of publication bias. Similarly, the distributions for IL-6 and TNF-α also showed a broadly symmetrical pattern, indicating that publication bias for these inflammatory markers was not prominent. In contrast, the funnel plots for the Mayo score and Baron endoscopy score displayed some degree of asymmetry. This observed asymmetry may point to the possible presence of publication bias or reflect underlying clinical and methodological heterogeneity among the included studies for these specific outcomes. Overall, while minor asymmetries were present for some measures, the funnel plot analysis did not provide clear evidence of substantial publication bias across the network meta-analysis. See Supplementary Material 10 for details.
3.7 Quality of evidence assessment
The overall certainty of evidence for the outcomes evaluated was moderate to low. Total effective rate was graded as moderate certainty, primarily limited by a serious risk of bias across studies due to inadequate reporting of randomization and allocation concealment, as well as the inherent challenges in blinding participants and practitioners. For Mayo score, Baron endoscopy score, and adverse events, the certainty was low. These ratings were influenced by serious risks of bias, considerable heterogeneity, and imprecision resulting from limited sample sizes and wide confidence intervals. Additionally, potential publication bias could not be excluded, given the predominance of positive results and regional concentration of studies (see Table 6 for details).
Table 6. Assessment of quality of evidence.
4 Discussion
4.1 Principal findings
This systematic review and network meta-analysis provides a comprehensive hierarchy of the relative efficacy and safety of various acupuncture-related therapies for UC, based on 76 RCTs. Our findings suggest several potentially important clinical implications:
1. For total effective rate: AA + CHM demonstrated the highest probability of being the best intervention. This highlights the potent synergistic effect that can be achieved by combining internal herbal medicine with external acupoint stimulation.
2. For promoting mucosal healing: Baron score assesses the extent of UC disease, and Mayo score assesses mucosal healing. Intestinal mucosal healing is considered to be a key goal of UC treatment, which is closely related to reducing the recurrence rate, reducing the risk of colectomy, and preventing colorectal cancer (107). ACU-CT was significantly better than the control group in improving colonoscopic scores, indicating that acupuncture combined therapy could promote the healing of the damaged intestinal mucosa and control the progression of the disease.
3. For reducing systemic inflammation: TNF-α and IL-6 are key cytokines involved in inflammatory and autoimmune processes and their overexpression is closely related to inflammatory damage to the intestinal mucosa (108). Our quantitative findings provide specific support for the anti-inflammatory potential of acupuncture therapies. The results showed that WA and WA-CT were the most effective interventions for lowering key pro-inflammatory cytokines IL-6 and TNF-α, respectively. This indicates that the thermal stimulation characteristic of warm acupuncture may have a specific and powerful anti-inflammatory effect, modulating the underlying immune dysregulation in UC.
4. For preventing disease relapse: ACU alone showed the greatest advantage in reducing recurrence rates. This remarkable finding suggests that conventional acupuncture may possess long-term regulatory effects that help sustain remission, potentially by restoring physiological balance and regulating the gut-brain axis.
5. Safety profile: The available data on adverse events consistently indicated that acupuncture-related therapies were associated with a lower incidence and severity of adverse events compared to conventional pharmaceutical treatments. This favorable safety profile positions these therapies as valuable complementary or alternative options, especially for patients intolerant to or seeking to reduce the burden of long-term drug use.
Acupoint analysis revealed that three studies using auricular acupressure all selected Spleen (MA-IC 3), Large Intestine (MA-IC 5), Endocrine (MA-AT 1), Sympathetic (MA-AH 7), and Subcortex (MA-AT 4). 2 studies using scalp acupuncture were used in both the stomach zone and intestinal zone. High-frequency acupoint analysis showed that Tianshu (ST25), Zusanli (ST36), Shangjuxu (ST37), and Zhongwan (CV12) were the most commonly used points. Tianshu is the Front-Mu point of the large intestine, which has the effect of regulating the gastrointestinal function and restoring normal intestinal motility and transformation. It is frequently used to relieve symptoms of bowel dysfunction such as abdominal pain, diarrhea, and constipation in UC patients, and is also a commonly selected point in experimental animal models of acupuncture for UC (109, 110). Therefore, the improvements in Mayo score and endoscopic outcomes observed in our study may be mechanistically underpinned by the widespread use of these pivotal acupoints, which are believed to exert multi-target effects. Zusanli is the Lower He-Sea point of the stomach, is known for harmonizing the stomach and intestines, regulating Qi of the Yangming meridian, enhancing immunity, and improving systemic function. Shangjuxu is the Lower He-Sea point of the large intestine, which has the effect of regulating the stomach and intestines, regulating qi and dissolving stagnation. Zhongwan is the Front-Mu point of the stomach, which has the effect of soothing the middle coke qi machine, and reducing stomach inversion and relieving pain. Acupuncture can regulate immune balance, reduce the expression of pro-inflammatory factors, and repair the intestinal mucosal barrier function, so it is effective for UC (111, 112).
The differences in the therapeutic efficacy of various acupuncture-related therapies for UC may be attributed to their distinct stimulation modalities, mechanisms of action, and intervention characteristics. Traditional manual acupuncture uses physical stimulation on the body surface as a method to regulate the immune response by activating the three anti-inflammatory pathways, including the cholinergic anti-inflammatory pathway, splenic sympathetic anti-inflammatory pathway, and the hypothalamic–pituitary–adrenal (HPA) axis (113). Electroacupuncture combines millineedle stimulation with electrical stimulation to enhance the amount of stimulation to acupuncture points, which can jointly stimulate the vagus nerve, activate the cholinergic anti-inflammatory pathway, and inhibit the expression of pro-inflammatory factors, thereby alleviating the inflammatory response of UC (114). Moxibustion stimulates meridian acupuncture points with warmth, strengthens the flow of qi and blood in the body, and regulates the intestinal flora by inhibiting the expression of IL-12 and TNF-α (115). Acupoint catgut embedding involves implanting absorbable sutures into specific acupoints, delivering prolonged and gentle stimulation. This method has been reported to support intestinal microecological balance and immune regulation, offering long-lasting and stable clinical efficacy (116). Auricular acupressure stimulates corresponding reflex points related to the affected internal organs, thereby promoting intestinal peristalsis and enhancing gastrointestinal function. Given the unique features of each intervention in stimulation method, intensity, and therapeutic mechanisms, personalized treatment approaches tailored to patients’ physical constitution and clinical presentation are warranted in future practice.
4.2 Strengths
This study has several notable strengths: (1) The literature search system is comprehensive, the sample size included is sufficient, and the variety of therapies is covered, which enhances the representativeness and stability of the conclusions; (2) The network meta-analysis method was used to achieve direct and indirect comparison between a variety of acupuncture-related therapies, thereby overcoming the limitations of traditional pairwise meta-analysis that are restricted to two-group comparisons. (3) Outcomes included symptom scores, endoscopic scores, serum inflammatory markers and recurrence rate, allowing for a multidimensional evaluation of therapeutic efficacy. (4) Acupuncture-related interventions demonstrated a low incidence of adverse events, indicating a favorable safety profile, highlighting the advantages of the holistic regulatory approach of traditional Chinese medicine.
4.3 Limitations
This study has several limitations: (1) Among the 76 RCTs, some studies only mentioned “randomization” without providing specific details on the randomization method. Moreover, most RCTs did not report blinding procedures or allocation concealment, which may affect the credibility of the risk of bias assessments. (2) Only a limited number of studies reported Baron endoscopic score and Mayo score, which may compromise the stability and generalizability of the analyses. (3) The majority of the included studies were conducted in China, introducing a potential regional bias. Therefore, the international applicability of the findings requires further validation. (4) Due to limitations in the original literature, interventions involving combination therapies (one of which is acupuncture-related therapy) were uniformly categorized as combination therapy, including ACU + MOX + WM, ACU + MOX + CHM, ACU + MOX + RE, etc. Given the diversity of combination therapy strategies, further clarification will be provided in future studies. (5) A small number of included studies did not fully report the details of their treatment schedules. While this does not undermine the primary findings of our network meta-analysis regarding the comparative efficacy of different therapy classes, it highlights a key area for improvement in future trial reporting to enhance reproducibility and clinical translation.
5 Conclusion
ACU, MOX, WA, and their combination therapies may represent the most effective treatment for UC. The identified core acupoints provide a standardized basis for clinical practice. The results of this analysis suggest that acupuncture has the potential to serve as a component of the comprehensive management strategy for UC and is expected to gain broader clinical application in the future. Future research should focus on conducting large-sample, high-quality RCTs with longer follow-up periods to confirm the long-term efficacy and to elucidate the specific mechanisms of action behind these distinct acupuncture interventions.
Data availability statement
The original contributions presented in the study are included in the article/Supplementary Material, further inquiries can be directed to the corresponding author.
Author contributions
LZ: Writing – review & editing, Writing – original draft, Methodology. YS: Methodology, Writing – review & editing, Writing – original draft. ZR: Software, Data curation, Writing – review & editing. DL: Writing – review & editing, Software, Data curation. YM: Writing – review & editing.
Funding
The author(s) declare financial support was received for the research and/or publication of this article. This work was supported by the State Administration of Traditional Chinese Medicine High Level Key Discipline Construction Project of Traditional Chinese Medicine-Traditional Chinese Medicine External Treatment (zyyzdxk-2023116).
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Generative AI statement
The authors declare that no Generative AI was used in the creation of this manuscript.
Any alternative text (alt text) provided alongside figures in this article has been generated by Frontiers with the support of artificial intelligence and reasonable efforts have been made to ensure accuracy, including review by the authors wherever possible. If you identify any issues, please contact us.
Publisher’s note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
Supplementary material
The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fmed.2025.1676608/full#supplementary-material
References
1. Gros B, Kaplan G. Ulcerative colitis in adults: a review. JAMA. (2023) 330:951–65. doi: 10.1001/jama.2023.15389
2. Le Berre C, Honap S, Peyrin-Biroulet L. Ulcerative colitis. Lancet. (2023) 402:571–84. doi: 10.1016/s0140-6736(23)00966-2
3. Molodecky N, Soon I, Rabi D, Ghali W, Ferris M, Chernoff G, et al. Increasing incidence and prevalence of the inflammatory bowel diseases with time, based on systematic review. Gastroenterology. (2012) 142:46–54.e42. doi: 10.1053/j.gastro.2011.10.001
4. Tamir-Degabli N, Maharshak N, Cohen N. Salvage therapy in acute severe ulcerative colitis: current practice and a look to the future. Turk J Gastroenterol. (2023) 34:576–83. doi: 10.5152/tjg.2023.23103
6. Li W, Zhao T, Wu D, Li J, Wang M, Sun Y, et al. Colorectal cancer in ulcerative colitis: mechanisms, surveillance and chemoprevention. Curr Oncol. (2022) 29:6091–114. doi: 10.3390/curroncol29090479
7. Regueiro M, Greer J, Szigethy E. Etiology and treatment of pain and psychosocial issues in patients with inflammatory bowel diseases. Gastroenterology. (2017) 152:430–9.e4. doi: 10.1053/j.gastro.2016.10.036
8. Barberio B, Segal J, Quraishi M, Black C, Savarino E, Ford A. Efficacy of oral, topical, or combined oral and topical 5-aminosalicylates, in ulcerative colitis: systematic review and network meta-analysis. J Crohns Colitis. (2021) 15:1184–96. doi: 10.1093/ecco-jcc/jjab010
9. Ford A, Bernstein C, Khan K, Abreu M, Marshall J, Talley N, et al. Glucocorticosteroid therapy in inflammatory bowel disease: systematic review and meta-analysis. Am J Gastroenterol. (2011) 106:590–9. doi: 10.1038/ajg.2011.70
10. Kobayashi T, Siegmund B, Le Berre C, Wei S, Ferrante M, Shen B, et al. Ulcerative colitis. Nat Rev Dis Primers. (2020) 6:74. doi: 10.1038/s41572-020-0205-x
11. Honap S, Jairath V, Danese S, Peyrin-Biroulet L. Navigating the complexities of drug development for inflammatory bowel disease. Nat Rev Drug Discov. (2024) 23:546–62. doi: 10.1038/s41573-024-00953-0
12. da Silva B, Lyra A, Rocha R, Santana G. Epidemiology, demographic characteristics and prognostic predictors of ulcerative colitis. World J Gastroenterol. (2014) 20:9458–67. doi: 10.3748/wjg.v20.i28.9458
13. Dongdong Z, Yanjun Z, Yeshan Z. Observation on the efficacy of warm needling therapy combined with western medicine in the treatment of ulcerative colitis. Shanghai J Acupunct Moxibustion. (2022) 41:443–9. doi: 10.13460/j.issn.1005-0957.2022.05.0443
14. Yanjun Z, Yujie C, Dongdong Z, Shixu G, Qiaoling W. Clinical study on warm acupuncture combined with bukou buxu decoction in the treatment of ulcerative colitis with spleen-kidney yang deficiency syndrome. Shaanxi J Traditional Chinese Med. (2021) 42:1470–3.
15. Li Z, Lingling Z, Xiaojian J. The efficacy of warm acupuncture combined with Shenling Baizhu Powder in the treatment of ulcerative colitis with spleen deficiency and dampness obstruction syndrome and its effects on brain-gut interaction and inflammatory factors. Hebei J Traditional Chinese Med. (2021) 43:1483–14871524.
16. Chao Z, et al. Analysis of acupuncture treatment strategies for ulcerative colitis. China’s Naturopathy. (2021) 29:1–3. doi: 10.19621/j.cnki.11-3555/r.2021.0301
17. Luqiang S, Wei Z, Tao W, Fangli L, Ying L. Research progress on the effects of acupuncture on intestinal microbiota. Hunan J Traditional Chinese Med. (2018) 34:190–3. doi: 10.16808/j.cnki.issn1003-7705.2018.01.084
18. Wenrui J, Qingguo L, Wei W, Xiaolan S, Jianqin Y, Xin W, et al. Research progress on the mechanism of acupuncture in treating ulcerative colitis. Global Traditional Chinese Med. (2021) 14:1912–6.
19. Zongri H, Pingliang S. Research progress on acupoint therapy for ulcerative colitis. Chinese J Library Inf Sci Traditional Chinese Med. (2021) 45:74–6.
20. Hao J, Zhao Y, Cao Y, Wang H, Ji L. Electroacupuncture for ulcerative colitis patients: a meta-analysis and acupoints selection study. Heliyon. (2023) 9:e20789. doi: 10.1016/j.heliyon.2023.e20789
21. Yu Y, Zhou M, Tong Y, Yin S, Hu G, Jian W, et al. Meta-analysis and trial sequential analysis of acupoint catgut embedding in the treatment of ulcerative colitis: acupoint catgut embedding treating ulcerative colitis meta-analysis. Medicine. (2022) 101:e30945. doi: 10.1097/MD.0000000000030945
22. Wang X, Zhao N, Sun Y, Bai X, Si J, Liu J, et al. Acupuncture for ulcerative colitis: a systematic review and meta-analysis of randomized clinical trials. BMC Complement Med Ther. (2020) 20:309. doi: 10.1186/s12906-020-03101-4
23. Lee D, Kim J, Lee M, Choi T, Choi S, Ernst E. Moxibustion for ulcerative colitis: a systematic review and meta-analysis. BMC Gastroenterol. (2010) 10:36. doi: 10.1186/1471-230X-10-36
24. Page M, McKenzie J, Bossuyt P, Boutron I, Hoffmann T, Mulrow C, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. (2020) 372:n71. doi: 10.1136/bmj.n71
25. Hutton B, Salanti G, Caldwell D, Chaimani A, Schmid C, Cameron C, et al. The PRISMA extension statement for reporting of systematic reviews incorporating network meta-analyses of health care interventions: checklist and explanations. Ann Intern Med. (2015) 162:777–84. doi: 10.7326/M14-2385
26. Sterne J, Savović J, Page M, Elbers R, Blencowe N, Boutron I, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. (2019) 366:l4898. doi: 10.1136/bmj.l4898
27. Guyatt G, Oxman A, Vist G, Kunz R, Brozek J, Alonso-Coello P, et al. GRADE guidelines: 4. Rating the quality of evidence–study limitations (risk of bias). J Clin Epidemiol. (2011) 64:407–15. doi: 10.1016/j.jclinepi.2010.07.017
28. Turner R, Davey J, Clarke M, Thompson S, Higgins J. Predicting the extent of heterogeneity in meta-analysis, using empirical data from the Cochrane database of systematic reviews. Int J Epidemiol. (2012) 41:818–27. doi: 10.1093/ije/dys041
29. Chawla N, Anothaisintawee T, Charoenrungrueangchai K, Thaipisuttikul P, McKay G, Attia J, et al. Drug treatment for panic disorder with or without agoraphobia: systematic review and network meta-analysis of randomised controlled trials. BMJ. (2022) 376:e066084. doi: 10.1136/bmj-2021-066084
30. da Costa B, Juni P. Systematic reviews and meta-analyses of randomized trials: principles and pitfalls. Eur Heart J. (2014) 35:3336–45. doi: 10.1093/eurheartj/ehu424
31. van Valkenhoef G, Dias S, Ades A, Welton N. Automated generation of node-splitting models for assessment of inconsistency in network meta-analysis. Res Synth Methods. (2016) 7:80–93. doi: 10.1002/jrsm.1167
32. Salanti G, Ades A, Ioannidis J. Graphical methods and numerical summaries for presenting results from multiple-treatment meta-analysis: an overview and tutorial. J Clin Epidemiol. (2011) 64:163–71. doi: 10.1016/j.jclinepi.2010.03.016
33. Dias S, Welton NJ, Sutton AJ, Ades AE. NICE DSU Technical Support Document 2: A Generalised Linear Modelling Framework for Pairwise and Network Meta-Analysis of Randomised Controlled Trials. London: National Institute for Health and Care Excellence (NICE) (2014).
34. Hongbo Z, et al. Clinical observation of 33 cases of ulcerative colitis treated with jiawei baitouweng decoction for enteral drip combined with acupoint catgut embedding. J Traditional Chinese Med. (2012) 53:2112–21. doi: 10.13288/j.11-2166/r.2012.24.012
35. Yue Z, Zhenhui Y. Acupuncture at jiaji points combined with plum-blossom needle tapping for treating 43 cases of ulcerative colitis. J Traditional Chinese Med. (2003) 44:282–3.
36. Defang W, Ming Z, Xiaoyan L. Observation on the efficacy of acupuncture combined with modified scutellaria decoction in treating active ulcerative colitis (dampness-heat accumulation syndrome). Guide J Traditional Chinese Med Pharmacol. (2022) 28:71–5.
37. Min C. Clinical observation of 40 cases of ulcerative colitis treated with meridian-focused moxibustion combined with Wenzhong Guyuan decoction. J Traditional Chinese Med. (2009) 15:49–50.
38. Puyu F, Ning W. The effect of Baitouweng decoction combined with penetrating moxibustion on inflammatory cytokines and immune function in patients with damp-heat type ulcerative colitis. J Traditional Chinese Med. (2021) 36:1335–8. doi: 10.16368/j.issn.1674-8999.2021.06.280
39. Guoying Z, Jianhong J. Clinical observation of electroacupuncture combined with moxibustion and medication in the treatment of ulcerative colitis. J Traditional Chinese Med. (2008) 2008:2069–71. doi: 10.13193/j.archtcm.2008.09.230.zhougy.088
40. Baocai X, Wei C. Evaluation of the effect of lei’s silver cup moxibustion with ginger partition combined with the fire-reinforcing earth-generating method on ulcerative colitis in remission. Chinese General Pract. (2022) 20:844–902. doi: 10.16766/j.cnki.issn.1674-4152.002469
41. Wenwen Z, Zhanbo J, Qingfeng W, Chunzhi L, Dongning W, Yixin J, et al. Bioinformatics study on the mechanism of umbilical moxibustion therapy on the BTNL2-HLA signaling pathway in patients with ulcerative colitis. Chinese J Information Traditional Chinese Med. (2019) 26:18–23.
42. Zhouyu Y, Dingyan B, Zhan Y, Yongheng H. Clinical study on herbal cake-separated moxibustion for mild to moderate ulcerative colitis with spleen deficiency and dampness accumulation syndrome. Chinese J Inf Traditional Chinese Med. (2017) 24:32–5.
43. Yi H, Yafeng Z, Xi L, Ning L, Wei C, Wenwu D, et al. Therapeutic efficacy of yu kuining formula enema combined with heat-sensitive moxibustion in the treatment of ulcerative colitis (dampness-heat accumulation syndrome) and its immunomodulatory mechanism. J Emerg Traditional Chinese Med. (2021) 30:694–7.
44. Qiang Z, Yanan L, Peichao Q, Yongming W, Xinjun L. Clinical study on the ‘using fire to chase the dragon fire’ method combined with he-mu point acupuncture for the treatment of acute ulcerative colitis. J Emerg Traditional Chinese Med. (2018) 27:233–6.
45. Ying Z, Weijian Y, Hongyan Y. The effect of acupoint catgut embedding on serum IL-2 receptor and T lymphocyte subsets in patients with ulcerative colitis. Chinese J Integr Traditional Western Med. (2003) 23:58–9.
46. Chunquan S, Jinling L, Tiantian D, Yazheng P, Jiguo Y. Clinical observation of umbilical moxibustion therapy combined with mesalazine in the treatment of ulcerative colitis with spleen-kidney yang deficiency syndrome. Chinese J Integr Traditional Western Med Digestion. (2017) 25:525–8.
47. Sheng M, Guilan Z. Observation on the efficacy of combined acupuncture and moxibustion in treating 60 cases of ulcerative colitis. Chinese Acupunct Moxibustion. (1997):275–6.
48. Songmei W, Xingguo L, Liqun Z, Yingchun X, Qing L. Clinical observation of shenque (CV8) herbal-cake-separated moxibustion therapy for ulcerative colitis. Chinese Acupunct Moxibustion. (2006) 26:97–9.
49. Hongjun L, Guoping L, Hongyan L. Clinical observation of acupoint catgut embedding therapy for ulcerative colitis. Chinese Acupunct Moxibustion. (2006):261–3.
50. Jinjie K, Liming Y, Qingxin C. Observation on the effect of Banxia Xiexin decoction combined with abdominal acupuncture in the treatment of mild to moderate active ulcerative colitis with dampness-heat syndrome of the large intestine. Med Innov China. (2022) 19:90–3.
51. Ziying W. Comparison of the efficacy of acupuncture combined with oral Chinese herbal medicine in the treatment of chronic nonspecific ulcerative colitis. J Zhejiang Chinese Med Univer. (2015) 39:315–6. doi: 10.16466/j.issn1005-5509.2015.04.019
52. Yanjun Z, Yujie C, Dongdong Z. The effect of regulating spleen and stomach with warming and cooling needling method on Th17/Treg balance and cytokine levels in patients with ulcerative colitis. Modern J Integr Traditional Chinese Western Med. (2021) 30:24–9. doi: 10.3969/j.issn.1008-8849.2021.01.005
53. Hong G. The effect of acupoint catgut embedding therapy on the intestinal mucosa of patients with ulcerative colitis. Modern J Integr Traditional Chinese Western Med. (2020) 29:288–90.
54. Xue F, Ziqi L, Xiaoming G, Jiena P. Analysis of the efficacy of acupuncture and moxibustion in traditional chinese medicine for treating chronic ulcerative colitis. Clin J Diabetes World. (2020) 17:43.
55. Guiying Z, Yujie C, Xuelian D, Xiaolei Z, Yanjun Z. Clinical observation on the treatment of ulcerative colitis with midnight-midday ebb-flow herbal retention enema combined with heat-sensitive moxibustion. J Sichuan Traditional Chinese Med. (2017) 35:77–9.
56. Liqun L. Clinical observation of bupiwei xieyinhuo shengyang decoction combined with heat-sensitive moxibustion in the treatment of ulcerative colitis. J Sichuan Traditional Chinese Med. (2017) 35:95–7.
57. Baojun G, Peng L, Leixiao Z, Dongdong M, Siyi Y, Zhifu S, et al. Observation on the therapeutic effect of acupuncture for strengthening the spleen and nourishing the kidney in treating ulcerative colitis. J Sichuan Traditional Chinese Med. (2016) 34:182–5.
58. Jie C. Clinical observation on specific acupoint thread embedding therapy for chronic non-specific ulcerative colitis. J Sichuan Traditional Chinese Med. (2004):89–90.
59. Yujie C, Yanhong W, Xuelian D, Xiaolei Z, Siyu D. Randomized controlled study on moxibustion at shenque and bazhen acupoints combined with chinese herbal medicine enema in the treatment of ulcerative colitis. J Sichuan Traditional Chinese Med. (2017) 35:199–202.
60. Hailin W, Min C, Bo H, Heng W, Zhihua H, Zecai C, et al. Clinical study on tongxie yaofang combined with electroacupuncture in the treatment of ulcerative colitis with liver-spleen disharmony pattern. J Sichuan Traditional Chinese Med. (2020) 38:124–7.
61. Tianshu X, Wei D. Observation on the efficacy of combined acupuncture and medication in treating mild to moderate non-specific ulcerative colitis. Pract Prevent Med. (2009) 16:1564–6.
62. Lingyun G, Qingshan Z, Shuyun Z, Xinjie Z. Clinical observation of wumei pill combined with thunder-fire moxibustion in the treatment of ulcerative colitis. J Clin Med Pract. (2016) 20:131–2.
63. Wensong X, Lucui W, Jinzhou W, Fang Z. Efficacy of acupuncture combined with chinese herbal medicine in the treatment of ulcerative colitis and its impact on related indicators. Shanghai J Acupunct Moxibustion. (2019) 38:378–83. doi: 10.13460/j.issn.1005-0957.2019.04.0378
64. Qun S, Yunlu Z, Jing L. Observation on the efficacy of indirect moxibustion with aconite cake combined with mesalazine in the treatment of ulcerative colitis with damp-heat type. Shanghai J Acupunct Moxibustion. (2019) 38:374–7. doi: 10.13460/j.issn.1005-0957.2019.04.0374
65. Qun S, Jing L, Songming G. Observation on the therapeutic effect of acupuncture at the Shizi point as the main treatment for ulcerative colitis. Shanghai J Acupunct Moxibustion. (2012) 31:319–20.
66. Zong W, Yi L, Zhu Y. Acupoint catgut embedding therapy for mild to moderate ulcerative colitis: a report of 34 cases. Shaanxi J Traditional Chinese Med. (2015) 36:98–100.
67. Hongfei D, Jian H, Chunyan H. Comprehensive therapy for chronic ulcerative colitis: a clinical study of 42 cases. Shandong J Traditional Chinese Med. (2008) 27:304–6. doi: 10.3969/j.issn.0257-358X.2008.05.009
68. Weiwei H, Zhimei W, Liangliang X. Clinical efficacy of indirect moxibustion combined with mesalazine in the treatment of ulcerative colitis and its effects on serum immunoglobulin, interleukin-17, and thromboxane B2. J Clin Exp Med. (2018) 17:2097–101.
69. Jia Y, Chang L, Meiping Z. Clinical efficacy of Tongxie Decoction combined with acupuncture in the treatment of ulcerative colitis and its effects on serum inflammatory factors and intestinal flora. Liaoning J Traditional Chinese Med. (2024) 51:159–62. doi: 10.13192/j.issn.1000-1719.2024.06.042
70. Hu W. Clinical study on electroacupuncture at dachangshu and front-mu points for ulcerative colitis. Liaoning J Traditional Chinese Med. (2022) 49:173–5. doi: 10.13192/j.issn.1000-1719.2022.11.045
71. Yanru D, et al. Observation on the efficacy of combining acupuncture and medication in treating 89 cases of ulcerative colitis. Liaoning J Traditional Chinese Med. (2007) 34:65–65. doi: 10.3969/j.issn.1000-1719.2007.01.045
72. Longling C, Yonghui L, Yuanquan Z. Clinical value analysis of acupuncture combined with changyanqing in the treatment of ulcerative colitis with dampness-heat syndrome of large intestine in active stage. Liaoning J Traditional Chinese Med. (2018) 45:811–5. doi: 10.13192/j.issn.1000-1719.2018.04.047
73. Juhua Z. Clinical observation of 34 cases of ulcerative colitis treated with ginger-partitioned moxibustion. Jiangsu J Traditional Chinese Med. (2003):44–5.
74. Fei G, Shilin Z, Mingbing X, Xiaoping M, Yu J, Yajun W, et al. Study on the mechanism of electroacupuncture combined with drug therapy in the treatment of UC based on the brain-gut axis—with 31 clinical cases included. Jiangsu J Traditional Chinese Med. (2014) 46:65–6.
75. Runlian Z, Guanglin N, Xueqing H, Shuyu W. Observation on the efficacy of traditional chinese medicine retention enema combined with acupuncture in the treatment of ulcerative colitis. Jilin J Chinese Med. (2012) 32:270–1.
76. Yan C, Zheng Y. Study on the effect of heat-sensitive moxibustion combined with kangfuxin liquid enema in the treatment of ulcerative colitis. Chinese Nurs Res. (2013) 27:1970–1.
77. Chunxia X, Rongjun L, Xiaoli Y, Jian W, Yan Y. Clinical observation on treating ulcerative colitis from the perspective of the lung using Jingjie Lianqiao decoction combined with acupuncture at Guiyan point. J Hunan Univer Chinese Med. (2023) 43:338–42.
78. Haiping W. Clinical efficacy of Qingre Huashi decoction combined with acupuncture in the treatment of ulcerative colitis and its effect on serum inflammatory factors. J Hubei Univer Chinese Med. (2020) 22:78–80.
79. Yang T, Weiguo D, Shaoqian T. Combination of patrinia mixture and dense wave electroacupuncture in the treatment of 40 cases of ulcerative colitis. Henan Traditional Chinese Med. (2014) 34:2362–5. doi: 10.16367/j.issn.1003-5028.2014.12.067
80. Hongchang Z, Shukai H, Jinyou D. 50 cases of chronic non-specific ulcerative colitis treated with qi-replenishing, blood-activating, and collateral-dredging formula combined with scalp acupuncture. Hebei J Traditional Chinese Med. (2009) 31:538–9.
81. Shiqiang C. Acupuncture combined with drug enema in the treatment of 40 cases of chronic ulcerative colitis. Hebei J Traditional Chinese Med. (2001) 852.
82. Yanhua B, Zhenyu Y, Yuzhu S. Clinical observation of Lian Yang San retention enema combined with acupuncture therapy in the treatment of chronic non-specific ulcerative colitis. Hebei J Traditional Chinese Med. (2014) 36:212–49.
83. Jun H, Muxi L, Zhenzhen M. Clinical efficacy of acupuncture combined with umbilical ring moxibustion with ginger for spleen-kidney yang deficiency ulcerative colitis and its effects on related inflammatory factors. J Guangzhou Univer Traditional Chinese Med. (2015) 32:687–93. doi: 10.13359/j.cnki.gzxbtcm.2015.04.024
84. Jianping H, Li L, Jianrong H, Xiaoquan D. Colonic drip combined with ginger-partitioned moxibustion in the treatment of ulcerative colitis: a clinical observation. J Basic Chinese Med. (2012) 18:1027–9. doi: 10.19945/j.cnki.issn.1006-3250.2012.09.042
85. Sha L, Xiaofeng J, Huan Q, Yan S, Jiaming L. The therapeutic effect of Huangqi Jianzhong decoction combined with moxibustion on patients with ulcerative colitis of spleen deficiency and dampness accumulation type and its impact on T cell subsets. Chinese J Integr Traditional Western Med Digestion. (2021) 29:879–85.
86. Guangquan W, Minghai Y. Acupuncture combined with herbal enema in the treatment of 45 cases of ulcerative colitis. Med Innov China. (2010) 7:168–9.
87. Hong L. Clinical observation of the therapeutic effect of comprehensive acupuncture and moxibustion therapy on ulcerative colitis. Psychol Doctor. (2016) 22:6–7.
88. Yanjun Z, Yujie C, Dongdong Z, Shixu G, Qiaoling W. Observation on the efficacy of regulating the spleen and stomach with warming and cooling acupuncture based on the theory of “earth as the pivot and four phenomena, one qi circulating” in the treatment of ulcerative colitis. Modern J Integr Traditional Chinese Western Med. (2020) 29:3901–6. doi: 10.3969/j.issn.1008-8849.2020.35.006
89. Kun W, Mei W. Observation on the efficacy of modified shaoyao decoction combined with acupuncture in treating active ulcerative colitis with dampness-heat accumulation syndrome. Modern J Integr Traditional Chinese Western Med. (2020) 29:763–6.
90. Hong W, Zhaoxia C, Xin W, Lirong L. Observation on the efficacy of traditional Chinese medicine in treating and nursing ulcerative colitis. Modern J Integr Traditional Chinese Western Med. (2008):5205–6. doi: 10.1016/j.phymed.2023.155052
91. Liqun L, Yan L, Lei Z. Randomized controlled study on the treatment of ulcerative colitis with traditional Chinese medicine retention enema combined with moxibustion. World J Integr Traditional Western Med. (2017) 12:970–3. doi: 10.13935/j.cnki.sjzx.170720
92. Jiannan J. The effect of combined acupuncture and medication on T cell subsets in patients with ulcerative colitis. Shanghai J Acupunct Moxibustion. (2015) 34:63–5. doi: 10.13460/j.issn.1005-0957.2015.09.0858
93. Weiwei Z, Linkang P, Xingshan L. Observation on the efficacy of kuijie formula combined with medicinal partition moxibustion in the treatment of ulcerative colitis with dampness-heat in the large intestine. J Shandong Univer Traditional Chinese Med. (2020) 44:410–3.
94. Chunling L, Linghua L, Xu H, Jie Y, Heng Z. Clinical observation of acupuncture at mu points combined with oral mesalazine in the treatment of ulcerative colitis. J Kunming Med Univer. (2024) 45:72–8.
95. Hao X, Jian G, Shun L. Clinical study on modified Zhenren Yangzang decoction combined with moxibustion for ulcerative colitis with spleen-kidney yang deficiency syndrome. Hebei J Traditional Chinese Med. (2020) 42:700–4.
96. Haiyan H. Clinical observation of acupuncture combined with modified Shenling Baizhu powder in the treatment of ulcerative colitis with spleen deficiency and dampness-heat syndrome. J Guangzhou Univer Traditional Chinese Med. (2022) 39:586–93. doi: 10.13359/j.cnki.gzxbtcm.2022.03.021
97. Bing W. Stellate ganglion block combined with acupoint catgut embedding for ulcerative colitis. Anhui Med Pharm J. (2013) 17:1784–5.
98. Shukai H, Hongchang Z, Wenge S, Jinyou D. Treatment of 50 cases of chronic ulcerative colitis with the method of Tonifying Qi, activating blood circulation, and dredging collaterals combined with scalp acupuncture therapy. J Traditional Chinese Med. (2009) 50:330–1. doi: 10.13288/j.11-2166/r.2009.04.038
99. Yanru D, Yanxia Z, Shengzhen S, Wan Z, Zhikun W. Clinical efficacy observation of combining acupuncture and medicine in treating 89 cases of ulcerative colitis. J Traditional Chinese Med. (2008) 49:314–6. doi: 10.3321/j.issn:1001-1668.2008.04.010
100. Hongchang Z, Shukai H, Jinyou D. Observation on the Efficacy of Scalp Acupuncture Combined with Sulfasalazine in the Treatment of 46 Cases of Chronic Ulcerative Colitis. J Emerg Traditional Chinese Med. (2010) 19:220–43.
101. Yanru D, Diangui L, Wan Z, Feng Z, Qiquan L. The effect of combining acupoint therapy with medication on clinical efficacy and SOD, NO levels in patients with ulcerative colitis (UC). China J Chinese Materia Med. (2008) 33:2404–6. doi: 10.3321/j.issn:1001-5302.2008.20.029
102. Xiaoying L, Wenjia W, Qin Q, Qi L, Mengdie W, Huangan W, et al. Clinical efficacy of moxibustion in the treatment of ulcerative colitis and its effect on vitamin D receptors. J Acupunct Tuina Sci. (2023) 21:40–50.
103. Xiangdong W, Xuanfeng D, Weili D. 40 cases of ulcerative colitis treated with changning enema combined with Du Moxibustion. Shaanxi J Traditional Chinese Med. (2021) 33:1127–8.
104. Dongjiang D, Linna Z, Jianting Y, Haibo H, Qiuyun W, Liandi L. Clinical observation on acupoint catgut embedding combined with modified pulsatilla decoction enema in the treatment of chronic non-specific ulcerative colitis. Hebei J Traditional Chinese Med. (2012) 34:721–2.
105. Jian H. 36 cases of chronic nonspecific ulcerative colitis treated with herbal enema combined with acupuncture. J Guizhou Univer Traditional Chinese Med. (2001) 12:9. doi: 10.16588/j.cnki.issn1002-1108.2001.04.009
106. Xiaolan L, Xingqian L, Kai C, Qingfeng M, Qing Y. Clinical study on the combination of Chinese and western medicine retention enema with acupuncture in the treatment of ulcerative colitis. J Colorectal Anal Surg. (2008):161–3.
107. Seidelin J, Coskun M, Nielsen O. Mucosal healing in ulcerative colitis: pathophysiology and pharmacology. Adv Clin Chem. (2013) 59:101–23. doi: 10.1016/b978-0-12-405211-6.00004-8
108. Ziyu L, Yang Y. The correlation between intestinal flora distribution and serum TNF-α and IL-6 levels in patients with ulcerative colitis. Chinese J Coloproctol. (2024) 44:44–6.
109. Ling Y. Study on the regulatory effect of moxibustion pretreatment at Tianshu (ST25) acupoint on the TLR4/TRIF signaling pathway in the colon of rats with ulcerative colitis. Shanghai J Acupunct Moxibustion. (2019) 38:819–26. doi: 10.13460/j.issn.1005-0957.2019.08.0819
110. Huang Y, Ma Z, Cui Y, Dong H, Zhao J, Dou C, et al. Effects of herb-partitioned moxibustion on the mirna expression profiles in colon from rats with DSS-induced ulcerative colitis. Evid Based Complement Alternat Med. (2017) 2017:1767301. doi: 10.1155/2017/1767301
111. Liu Z, Jiao Y, Yu T, Wang H, Zhang Y, Liu D, et al. A review on the immunomodulatory mechanism of acupuncture in the treatment of inflammatory bowel disease. Evid Based Complement Alternat Med. (2022) 2022:8528938. doi: 10.1155/2022/8528938
112. Xueke Y, Guoshun S, Yu F, Aining Y, Wei Y. Research progress on the pathogenesis and integrated traditional Chinese and Western medicine treatment of ulcerative colitis. Chinese Arch Traditional Chinese Med. (2022) 40:158–62. doi: 10.13193/j.issn.1673-7717.2022.09.035
113. Song G, Fiocchi C, Achkar J. Acupuncture in inflammatory bowel disease. Inflamm Bowel Dis. (2019) 25:1129–39. doi: 10.1093/ibd/izy371
114. Jin H, Guo J, Liu J, Lyu B, Foreman R, Yin J, et al. Anti-inflammatory effects and mechanisms of vagal nerve stimulation combined with electroacupuncture in a rodent model of TNBS-induced colitis. Am J Physiol Gastrointest Liver Physiol. (2017) 313:G192–202. doi: 10.1152/ajpgi.00254.2016
115. Wang X, Lu Y, Wu L, Yu S, Zhao B, Hu H, et al. Moxibustion inhibits interleukin-12 and tumor necrosis factor alpha and modulates intestinal flora in rat with ulcerative colitis. World J Gastroenterol. (2012) 18:6819–28. doi: 10.3748/wjg.v18.i46.6819
Keywords: ulcerative colitis, acupuncture-related therapies, network meta-analysis, randomized controlled trials, systematic review
Citation: Zhang L, Sun Y, Ru Z, Li D and Ma Y (2025) Comparative clinical efficacy of acupuncture-related therapies for ulcerative colitis: a systematic review and network meta-analysis. Front. Med. 12:1676608. doi: 10.3389/fmed.2025.1676608
Received: 30 July 2025; Revised: 13 November 2025; Accepted: 24 November 2025;
Published: 12 December 2025.
Edited by:
Mohammad Shehab, Abdullah Al Salem University, KuwaitReviewed by:
Antonella Smeriglio, University of Messina, ItalyShreyashi Pal, Birla Institute of Technology, Mesra, India
Jiazhen Cao, Changchun University of Chinese Medicine, China
Copyright © 2025 Zhang, Sun, Ru, Li and Ma. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Yuxia Ma, bWF5dXhpYTIwMjVAMTYzLmNvbQ==
†These authors have contributed equally to this work