Rédacteurs : Johan Nguyen, Claude Pernice

Diabetes

Diabète

1. Systematic Reviews and Meta-Analysis

☆☆☆ Evidence for effectiveness and a specific effect of acupuncture
☆☆ Evidence for effectiveness of acupuncture
Limited evidence for effectiveness of acupuncture
Ø No evidence or insufficient evidence

1.1. Generic Acupuncture

1.1.1. Chen 2019

Chen C, Liu J, Sun M, Liu W, Han J, Wang H. Acupuncture for type 2 diabetes mellitus: A systematic review and meta-analysis of randomized controlled trials. Complement Ther Clin Pract. 2019:100-112. [200050].

BackgroundAcupuncture has been used to treat type 2 diabetes (T2DM) for 2000 years and there are emerging clinical evidence and animal studies for its efficacy. However, we are unable to conclude the effectiveness and safety on this issue yet. OBJECTIVES: To assess the effects and safety of acupuncture for T2DM.
Methods We systematically searched 5 databases and 2 clinical registry platforms from inception to 2018-6-4. RCTs for acupuncture or its variants compared with sham acupuncture or no acupuncture controls for T2DM were included. The primary outcomes were glycemic control and adverse events.
Results A total of 21 studies, which comprised a total of 1943 participants, were included in the final meta-analysis. Compared with sham acupuncture or no acupuncture plus baseline treatments, acupuncture plus baseline treatments yield reduction in FBG(MD 1.21 mmol/l, 95%CI 1.56 to 0.87), 2 h BG(MD 2.13 mmol/l, 95%CI 2.79 to 1.46), HA1c (MD 1.12%, 95%CI 1.62 to 0.62). Our results also show acupuncture can improve blood lipids and blood pressure control, and reduce weight.
ConclusionsAs one type of multifactorial intervention, acupuncture could be recommended as a supplementary treatment in the management of T2DM, especially in those with obesity or metabolic disorders. However, due to the small sample size, poor methodological quality of trials reviewed, the amount of evidence is not fully convincing. There is a need for well-planned, long-term studies.

1.1.2. Wu 2019

Wu L, Chen X, Liu Y, Lan J, Wu C, Li Z, Lu L, Yi W. Role of acupuncture in the treatment of insulin resistance: A systematic review and meta-analysis. Complement Ther Clin Pract. 2019:11-22. [205270]. DOI

Background and purpose Acupuncture has gained increasing attention in the treatment of insulin resistance (IR). This study systematically reviews the efficacy of acupuncture on clinical IR outcomes.
MethodsCochrane Central Register of Controlled Trials, Embase, Medline (via OVID), China National Knowledge Infrastructure (CNKI), Wan Fang and China Science and Technology Journal Database (VIP) were searched to collect randomized controlled trials (RCTs) of patients with IR treated by acupuncture. Meta-analysis was performed by RevMan 5.3.
Results With acupuncture, the homeostasis model assessment of insulin resistance (homa-IR) significantly decreased (mean difference (MD) = -1.04, 95% confidence interval (CI) -1.37 to -0.71; P < 0.00001), as did fasting blood glucose (FBG) (MD = -0.56, 95% CI -0.88 to -0.25; P = 0.0005), 2 h postprandial blood glucose (2hPG) (MD = -0.91, 95% CI -1.62 to -0.20; P = 0.01), and fasting insulin (FINS) (MD = -3.23, 95% CI -4.14 to -2; P < 0.00001). Meanwhile, the insulin sensitivity index (ISI) (MD = 0.36, 95% CI 0.18 to 0.53; P < 0.0001) increased, and fewer adverse events occurred.
ConclusionAcupuncture may improve homa-IR, ISI, FBG, 2hPG and FINS with fewer adverse events than other treatments, making it a viable treatment for IR.

1.1.3. Shi 2018

Shi Liwei, Ni Qing, Li Xiaowen, Du Lijuan. [Systematic Review of Interventional Effect of Acupuncture and Moxibustion on Impaired Glucose Regulation]. Journal of Fujian University of Traditional Chinese Medicine. 2018;1:60-66. [201789].

ObjectiveTo systematically assess the efficacy and safety of acupuncture and moxibustion on impaired glucose regulation.
Methods The databases of CNKI, VIP, Wan Fang, CBM, Pub Med,Embase,Clinicaltrails.gov and the Cochrane Library were searched to identify all published randomized controlled trials(RCTs) on acupuncture and moxibustion for treatment of impaired glucose regulation(IGR)from the database inception date to November 8,2016. Eligible studies were included. The Cochrane Risk of Bias tool was used to evaluate the methodological quality of the eligible studies. The statistical analysis was performed by Review Manager 5.3.
ResultsEleven RCTs with 970 participants were included. The methodological quality of the included studies was generally low. Six trials reported that its random sequence was generated by a random number table and one trial described the allocation concealment and blinding of outcome assessment. Publication bias was assessed by the funnel plot based on fasting plasma glucose(FPG) reported in the 11 trials. The funnel plot was asymmetrical, indicating that potential publication bias might influence the results of this review. Three trials reported the effect of acupuncture and moxibustion on improving glucose toleration. Two of the three trials showed that acupuncture and moxibustion could promote the normalization of glucose toleration, but the remaining one reported that there was no statistically significant difference between acupuncture plus lifestyle interventions and lifestyle interventions alone in improving glucose toleration(P <0.05). This review also showed that acupuncture and moxibustion were probably associated with the improvement of FPG and 2 h postprandial blood glucose(2 h PG). In view of the limited number of included studies and the significant heterogeneity among these trials, the review couldn’t assess the effects of acupuncture and moxibustion on improving blood glucose, hemoglobin A1 c(Hb A1 c),body mass index(BMI) and insulin resistance. Only one trial clearly reported that no adverse reactions occurred in the trial. Sensitivity analysis and Meta-analysis were not performed due to generally poor methodological quality, potential publication bias and the variety of clinical interventions.
Conclusions Acupuncture and moxibustion appears to play a role in the treatment of impaired glucose regulation, however, a firm conclusion about the efficacy and safety can not be drawn from this review due to the generally low methodological quality and small sample size. More evidence from high quality trials is needed to support the clinical use of acupuncture and moxibustion.

1.1.4. Song 2018 ☆

Song AQ, Zhang YP, Chen R, Liang FX. Is Acupuncture Effective for Improving Insulin Resistance? A Systematic Review and Meta-analysis. Curr Med Sci. 2018;38(6):1109-1116. [189853].

Objective This study aimed to evaluate the clinical efficacy of acupuncture for intervening insulin resistance (IR) by meta-analysis of related randomized controlled trials (RCTs).
MethodsStudies published prior to 31 January 2018 were searched on Pubmed, Medline, Cochrane Library, Embase databases and Chinese databases. Only RCTs, which examined acupuncture as the sole or adjunctive treatment for IR-related diseases, were included. The primary outcome was homeostasis model assessment for insulin resistance (HOMA-IR). The secondary outcomes consisted of fasting blood glucose (FBG), fasting insulin (FINS) and 2-h postprandial blood glucose (2h-PBG). The differences between groups were reported as mean differences (MD). All statistical analyses were performed using RevMan software 5.3. After carefully screening relevant studies,
Results9 RCTs involving 562 patients (279 in experimental group and 283 in control group) were enrolled in this study. The pooled results showed that acupuncture had significant effects on HOMA-IR (MD 0.70, 95% CI 0.04 to 1.35, P=0.04<0.05), FINS (MD 3.35 Mu/L, 95% CI 1.99 to 4.7, P<0.001) and 2h-PBG (MD 1.03 mmol/L, 95% CI 0.25 to 1.82, P=0.01). However, the differences in FBG were not significant (MD 0.28 mmol/L, 95% CI-0.28 to 0.84, P=0.32>0.05).
ConclusionsThe present meta-analysis indicated that acupuncture can help to improve IR to a certain extent, which remains to be confirmed by further high-quality RCTs.

1.1.5. Zheng 2016 ☆☆

Zheng Qi-Yan, Yang Hui-Sheng, Xiang Rong-Rong, Duyan-Yi, Lu Qin, Zhang Yu-Shuo, Wang Han, Wu Song. [Meta-analysis of acupuncture treatment for type 2 diabetes]. Shanghai Journal of Acupuncture and Moxibustion. 2016;5:618-622. [187053].

Objectives To systematically assess the efficacy and safety of acupuncture in treating type 2 diabetes.
Methods Methods Related literature was retrieved with a computer. After the data were sifted out from the literature according to the established criteria, they were collected and crossly checked by two researchers independently. The data were input to RevMan5. 2 for statistical analysis.
Results A total of ten studies were included with a total of 743 patients. The results of Meta-analysis showed 1) Post-treatment total efficacy rate was higher in the acupuncture or combined acupuncture and medicine group than in the control group [OR=3. 60, 95%CI (2. 11, 6. 13)] and there was a statistically significant difference (Z=4. 71, P<0. 00001); 2) Post-treatment range of decrease in fasting blood glucose (FBG) was significantly higher in the experiment group than in the control group [WMD=-1. 20, 95%CI (-1. 38, -1. 02)] and there was a statistically significant difference (Z=12. 88, P<0. 00001); 3) Post-treatment range of decrease in 2-h postprandial blood glucose (2hPBG) was significantly higher in the experiment group than in the control group [WMD=-1. 27, 95%CI (-1. 47, -1. 06)] and there was a statistically significant difference (Z=12. 02, P<0. 00001).
Conclusions Clinically acupuncture or combined acupuncture and medicine is more effective than Chinese herbal medicine or Western medication alone in treating T2DM and has no toxic and side effects.

1.1.6. Xing 2015 ☆

Xing Guo-Chun, Sun Zhi, Ma Yong-Chun, Fan Qun. [Meta-analysis of acupuncture on the pancreas islet function of patients with type-2 diabetes]. Journal of Nanjing University of Traditional Chinese Medicine(Natural Science). 2015;4:397-400. [187012].

Objectives To have a systematic evaluation of the influence of acupuncture on patients with type-2diabetes.
Methods Randomized controlled trials related to this subject were searched. HOMA-IR, ISI were used as the evaluation indexes to conduct the Meta-analysis.
Results Eight researches were selected and the Meta-analysis showed that fasting blood-glucose [WMD=-0. 81, 95%CI (-0. 98, -0. 64), P<0. 01], fasting insulin [WMD=-2. 67, 95%CI= (-3. 35, -1. 98), P<0. 01], insulin resistance index [WMD=-1. 51, 95%CI (-1. 96, -1. 06), P<0. 01], and insulin sensitivity index [WMD=0. 80, 95%CI (0. 36, 1. 24), P<0. 01]showed better improvement in the acupuncture groups than the control groups. The difference had statistical significance.
Conclusions Acupuncture can significantly improve the pancreas islet function of patients with type-2diabetes and is worthy of widely application.

1.1.7. Cai 2010 ☆

Cai Yan, Peng Chu-Xiang. [Meta-analysis on acupuncture treatment of diabetes]. Chinese Archives of Traditional Chinese Medicine. 2010;11:2412-241. [186930].

Objectives Systematic evaluation of the efficacy of acupuncture treatment of diabetic.
Methods I electronically searched CNKI, VIP, then the studies meeting the requirement were reviewed by Meta-analysis. Acupuncture retrieval of randomized controlled trials of diabetes and Meta Analysis.
Results Seven studies of randomized controlled trials of acupunctuae treatment of diabetes, Meta-analysis of results showed that acupuncture treatment of diabetes significantly. The total odds ratio (OR) = 7. 55, 95% CL was (4.71 to 12.10), There was a significant difference between the two (P < 0. 00001) “ Funnel plot” graphics show the existence of publication bias.
Conclusions The study shows Clinical efficacy of acupuncture treatment of diabetes significantly.

1.2. Special Acupuncture Techniques

1.2.1. Lee 2017 (pharmaco-acupuncture) ☆

Lee SW, Nam MH, Lee BC. Herbal acupuncture for type 2 diabetes: A meta-analysis. Exp Ther Med. 2017;13 (6):3249-325. [195251].

ObjectiveHerbal acupuncture (HA) is a modern adjunctive technique in which natural herbs or biologic substances are injected into acupuncture points. The objective of this systematic review was to evaluate evidence of the effectiveness of HA for type 2 diabetes mellitus (T2DM).
MethodsThree databases were searched. The included randomized controlled trials (RCTs) evaluated HA in controls and patients with T2DM and reported at least one of the following: Fasting blood glucose (FBG), postprandial (PP2hr) glucose and glycated hemoglobin (HbA1c).
ResultsIn a meta-analysis of seven RCTs (n=598 patients), HA significantly reduced levels of FBG, PP2hr glucose and HbA1c (P<0.0001, P=0.0005 and P=0.004, respectively). There was no significant effect of HA on total cholesterol, high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, or triglyceride level. High degrees of heterogeneity were present for all analyses except HDL-cholesterol and LDL-cholesterol.
Conclusions HA might have a beneficial effect on FBG, PP2hr glucose and HbA1c levels in patients with T2DM; however, because of several limitations, the results are inconclusive. Therefore, additional rigorous RCTs are warranted to overcome the limitations of previous studies.

1.2.2. Kim 2011 (moxibustion) Ø

Kim TH, Choi TY, Shin BC, Lee MS. Moxibustion for Managing Type 2 Diabetes Mellitus: A Systematic Review. Chinese Journal of Integrated Medicine. 2011;17(8):575-9. [158539].

Objectives Moxibustion is currently used for treating diabetes mellitus (DM) as a non-drug intervention in East Asian countries. This systematic review aims to evaluate the effectiveness of moxibustion for managing the symptoms of type 2 DM patients.
Methods We searched MEDLINE, AMED, EMBASE, CINAHL, The Cochrane Library, six Korean databases, and four Chinese databases. Risk of bias was used for evaluating the quality of the included studies.
Results A total of 5 studies met the inclusion criteria for this review. All of the included studies had high risks of bias. One randomized clinical trial (RCT) compared the effectiveness of one-time moxibustion use with oral administration of glibenclimide and showed the significant effects of moxibustion on glycemic control. Another RCT tested the effectiveness of moxibustion plus conventional treatment, and the moxibustion group reported significant improvement in fasting and postprandial blood glucose levels compared with the conventional treatment group. Two RCTs compared the effectiveness of moxibustion versus acupuncture or moxibustion plus acupuncture, and the combined treatment showed the most favorable effects on the control of blood glucose, urine glucose, and glycocylated hemoglobin A( 1C ) (HbA( 1C )). One uncontrolled observational study showed favorable effects of moxibustion on the response rate.
Conclusions It is difficult to conclude that moxibustion is an effective intervention for the control of type 2 DM due to the scarcity of trials and the low methodological quality of included studies. Further rigorous RCTs may be necessary to evaluate the effectiveness of moxibustion for type 2 DM.

1.3. Complications of diabetes

1.3.1. Diabetic Peripheral Neuropathy

1.3.2. Diabetic Foot

1.3.3. Diabetic gastroparesis

1.3.4. Diabetes and depression

1.3.4.1. Liu 2016 ☆

Liu Meijun, Liu Zhicheng, Xu Bin, Cai Jianwei. [Meta-analysis of acupuncture treatment of type 2 diabetes mellitus and depression clinical research]. Journal of Zhejiang University of Traditional Chinese Medicine. 2016;1:54-59. [187031].

Objectives To evaluate the clinical curative effect of acupuncture and moxibustion treatment of type 2 diabetes mellitus and depression, and safety.
Methods Computer retrieves Pubmed, Cochrane, Web of Science, CBM, CNKI, VIP and WanFang database, to find all about acupuncture and moxibustion treatment of type 2 diabetes mellitus and depression randomized controlled trial (RCT), before May 9, 2014, at the same time search by hand into literature references. According to inclusion and exclusion criteria, independently by two researchers after RCT extraction and filtering, data quality evaluation, adopting Revman5. 2 Meta-analysis software.
Results Three studies involving 256 patients were included. Meta-analysis showed: (1) the FPG: the results between the two groups were statistically significant (MD=1. 41, 95% CI= (1. 77, 1. 05)], showing that acupuncture and moxibustion treatment of type 2 diabetes mellitus and depression fasting blood glucose level was superior to the drugs. (2)2 HPBG: the results between the two groups statistically significant (MD=0. 67, 95% CI= (1. 07, 0. 27)], showing that acupuncture and moxibustion treatment of type 2 diabetes mellitus and depression postprandial 2 hours' blood glucose level was superior to the drugs. (3) HbA1c: the results between the two groups was statistically significant (MD=2. 38, 95% CI= (2. 61, 2. 16)], showing that acupuncture and moxibustion treatment of type 2 diabetes mellitus and depression level of glycated hemoglobin level is superior to the drugs. (4) HAMD: the results showed that the statistical significance was found between the two groups [MD=11. 76, 95% CI= (12. 20, 11. 33)], that acupuncture and moxibustion treatment of type 2 diabetes mellitus and Hamilton depression rating scale was superior to the drugs. (5) SDS: the results between the two groups had statistical significance [MD=11. 17, 95%CI= (11. 53, 10. 81)], showing that acupuncture and moxibustion treatment of type 2 diabetes mellitus and depression self rating scale score better than drugs.
Conclusions The curative effect of acupuncture and moxibustion treatment of type 2 diabetes mellitus and depression is superior to conventional drug treatment, due to the limitation of the evaluation into the research quality, it needs more high quality, large sample of RCT further argument.

2. Clinical Practice Guidelines

⊕ positive recommendation (regardless of the level of evidence reported)
Ø negative recommendation (or lack of evidence)

2.1. Canadian Diabetes Association (CDA, Canada) 2018 Ø

Diabetes Canada Clinical Practice Guidelines Expert Committee, Grossman LD, Robert Roscoe R, Shack AR. 2018 Clinical Practice Guidelines. Complementary and Alternative Medicine for Diabetes. Canadian Journal of Diabetes. 2018;42:S154-S161. [181265].

There is insufficient evidence to make a recommendation regarding efficacy and safety of complementary or alternative medicine [acupuncture] for individuals with diabetes [Grade D, Consensus].