It is a privilege to highlight the outstanding research conducted by Dr. Lu et al,1 who have won the Journal of the Chinese Medical Association (JCMA) Outstanding Research Award this year due to their remarkable impact. The study, titled “The Effects of Acupuncture and Related Techniques on Patients with Rheumatoid Arthritis: A Systematic Review and Meta-analysis,” elegantly bridges the gap between traditional eastern practices (including traditional Chinese Medicine [TCM]) and evidence-based western therapy (including western medicine [WM]) in the context of rheumatoid arthritis (RA) management.1 The authors attempted to test the effectiveness of using acupuncture and related techniques (ACNRT) in combination with WM in the management of patients with RA by undertaking a strenuous task in reviewing 755 documents, and subsequently narrowing down to 12 randomized controlled trials (RCTs) that met their inclusion criteria.1 By thoroughly analyzing these RCTs, the researchers convinced the audience with evidence to show that combination of ACNRT and WM offers an appreciable improvement RA patients’ inflammatory markers and clinical characteristics compared with the use of WM alone.1 This topic is very important because RA is a chronic and progressive autoimmune disease (AD) characterized by synovial membrane inflammation and hyperplasia, production of autoantibodies, cartilage and bone destruction and many other systemic pictures, resulting in the disability of suffered subjects and impairment of quality of life (QoL) and becoming a heavy socioeconomic burden in the world.1

Lu et al have undertaken a comprehensive systematic review and search of multiple English and Chinese databases, covering two decades of studies (between January 1, 2000, and January 31, 2021), to bring together to conduct a meta-analysis of 12 RCTs containing 874 subjects.1 Their choice of primary (measurement of inflammatory markers, such as C reactive protein [CRP], erythrocyte sedimentation rate [ESR], and rheumatoid factor [RF]) and secondary outcomes (evaluation of swollen joints count [SJC], tender joints count [TJC] visual analogue scale [VAS], disease-activity score [DAS], health assessment questionnaire [HAQ], and morning stiffness [MS]) offers a comprehensive understanding of the impact of integrated ACNRT to WM treatment on RA.1 The findings may offer a valuable perspective to healthcare providers and patients, wherein different treatment modalities work in synergy and/or augmentation rather than the use single approach alone based on the different mechanisms, suggesting that multimodality treatment strategy has become more and more popular, not only for providing a better therapeutic effect but also for offering a better QoL in recent clinical routine practice, regardless of which types of diseases (cancer, chronic illnesses, autoimmune diseases, and many others) are diagnosed.2–4 RA, causing pain, swelling, and stiffness in the joints, affects millions worldwide.5,6 TCM, preferring by many patients, has provided certain-degree symptomatic relief, but its therapeutic effects are reported to be limited.7,8 Therefore, the use of complementary and alternative medical approaches like ACNRT combined with standard treatment, such as adalimumab therapy5 by WM may hold an additional therapeutic effect or synergistic effect on outcomes and QoL of RA patients.

In evaluating the additional or synergistic benefits of ACNRTs on the WM for RA treatment, Lu et al using the tools commonly applicable to monitor the severity of RA compared the difference of the therapeutic responses between combination group (ACNRTs and WM) and VM alone.1 The authors found the inflammatory markers, such as CRP and ESR were dramatically and statistically significantly decreased in the combination group compared with VM alone group (weighted mean difference [WMD] −6.3, 95% confidence interval [CI], −9.08 to −3.52 for CRP; and WMD −6.56, 95% CI, −8.60 to −4.52 for ESR).1 Additionally, in term of disease-activity marker, such as RF, patients treated with combination therapy had a trend to show the decreased RF titers with WMD of −0.273 than patients treated with VM alone. For symptom controls, including measurement of disease-activity questionnaires, such as VAS, DAS-28, SJC, TJC, and MS, combination therapy offers a better disease control than VM alone with WMD of −1.09 for VAS, −1.09 for DAS, −1.92 for SJC, −1.49 for TJC, and −0.24 for MS, respectively.1 Although the authors found no significant improvement in overall HAQ scores between two groups, the trend to favor the combination therapy is still present (WMD −0.89).1 The authors tried to explain the reason about the absence of statistical significance of RF between two groups. They proposed that RF isotypes may play an unknown role and worthy of further investigation. It is traditionally known that elevated serum titer may be a marker to be correlated with more severe erosive disease of RA.9 Shin et al proposed that the disease activity is more severe in the group testing positive for RF compared with the group testing negative.10 Based on their finding, Dr. Shin et al commented that more aggressive and active treatment is needed for RA patients with positive RA and higher RA titer.10 Nevertheless, other studies did not support the aforementioned recommendation, because they found that the routine measurement of RF isotypes in monitoring disease activity or functional status seems to be unpracticable due to its low sensitivity and low specificity.11 Due to the aforementioned conflicted data, we suggest that more and more studies had better be conducted to establish the relationship between the RF and severity of RA. That is to say that not only RF titers but also individualized RF isotype titers are needed to be measured for all RA patients in the future studies.

In term of methodology of the present meta-analysis,1 the authors detected no significant publication bias. Their methodology and transparent reporting lend further credibility to their study, making it a valuable reference for future research.12–15 However, it is crucial to note that the discussion of results and the inclusive references should be appropriately positioned within the discussion section rather than being confined to the results section.

Taken together, the findings presented by Lu et al1 in this systematic review and meta-analysis provide strong evidence for the use of ACNRTs, including acupuncture, and electroacupuncture (EA), as effective supplementary interventions integrating to conventional WM for RA treatment, although the authors remain mindful of the limitations of their work and point out the need for longer-term, high-quality, multicenter RCTs with larger sample sizes. This study stands as a testament to the intersection of TCM and WM in providing effective treatment modalities for RA. We congratulate Lu et al1 for their significant contribution to the field and for their much-deserved outstanding research award.

ACKNOWLEDGMENTS

This article was supported by grants from the Taiwan National Science and Technology Council, Executive Yuan, Taiwan (MOST 110-2314-B-075-016-MY3 and MOST 111-2314-B-075-045), and Taipei Veterans General Hospital (V112C-154 and V112D64-001-MY2-1). The authors appreciate the support from Female Cancer Foundation, Taipei, Taiwan.

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