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Acupuncture ineffective for fibromyalgia

Clinical question Is standardized acupuncture effective in decreasing symptoms in patients with fibromyalgia?

Bottom line A standardized acupuncture protocol was no better than sham acupuncture in relieving pain or improving other symptoms in patients with significant fibromyalgia symptoms. Patients in all groups reported slightly better scores. Acupuncture is just one aspect of traditional Chinese medicine, however, and this fairly artificial study does not help us understand if this approach is effective. (Level of evidence = 1b)

Assefi NP, Sherman KJ, Jacobsen C, et al. A randomized clinical trial of acupuncture compared with sham acupuncture in fibromyalgia. Ann Intern Med. 2005;143:10-19.

Study design Randomized controlled trial (double-blinded)

Funding Government

Setting Outpatient (any)

Synopsis The researchers recruited by advertisement 100 people with a diagnosis of fibromyalgia, who had a global pain score of 4 or more (average=7) on a visual analog scale of 0 (no pain) to 10 (worst pain ever), and who agreed to maintain current treatment during the study. Using concealed allocation, the patients were randomized to receive either traditional Chinese medicine acupuncture according to a standardized (ie, not individualized) protocol (n=25) or 1 of 3 sham acupuncture treatments (n=25 patients each) administered by 8 practitioners. The participants were treated twice weekly for 12 weeks with acupuncture only. The study, in its attempt to maintain consistency of the acupuncture treatment, resulted in artificial treatment, since acupuncture is just one aspect of traditional Chinese medicine and the clinician usually adjusts treatment to the specific patients. Using intention-to-treat analysis, no differences were found in any outcome; pain intensity and fatigue intensity improved similarly in all 4 groups, as did sleep quality and overall well-being. Scores of general health status, as measured by the Short Form 36-Item Health Survey, did not change in any of the 4 groups.

Home glucose monitoring makes little difference in type 2 diabetes

Clinical question In patients with type 2 diabetes who are not using insulin, does home glucose monitoring improve care?

Bottom line Intensive monitoring of blood glucose in patients with type 2 diabetes not using insulin results in a small decrease in hemoglobin A1c (HbA1c) levels but does not change fasting blood glucose levels. Urine glucose monitoring works just as well. More casual monitoring of blood glucose, such as once a day, has not been studied. There is a strong possibility that the weak study design was largely responsible for the difference seen in the study. Blood glucose monitoring is expensive: At the intense level of monitoring used in some of these studies (6 times a day), the cost of the monitoring strips alone can be $2000 US per year. (Level of evidence = 1a)

Welschen LM, Bloemendal E, Nijpels G, et al. Self-monitoring of blood glucose in patients with type 2 diabetes who are not using insulin. Diabetes Care. 2005;28:1510-1517.

Study design Meta-analysis (randomized controlled trials)

Funding Self-funded or unfunded

Setting Outpatient (any)

Synopsis The researchers conducting this meta-analysis started by searching 3 databases for randomized controlled studies evaluating blood glucose self-monitoring with typical care in patients with type 2 diabetes who were not using insulin. They also searched the reference lists of identified studies for other studies. They did not attempt to find unpublished studies, research that’s usually rejected because it doesn’t find a difference. Two authors independently reviewed the studies for inclusion and evaluated the methodologic quality, and 2 authors independently extracted the data. The study quality was moderate for 4 of the studies and high for 2 of the studies. However, patients in the 6 studies included in this analysis were not blinded. Concealed allocation was either not done or not described in any of the studies, allowing the very real possibility that the patients in the blood glucose monitoring groups were different from those in the control groups. They were also highly motivated patients; patients doing the self-monitoring checked blood glucose levels from twice every other day to 6 times per day, 6 days per week. The comparison groups in the study either did no self-monitoring or monitored urine glucose. In the 5 studies that compared blood glucose monitoring with no monitoring, HbA1c levels were nominally but significantly lower in the blood glucose monitoring group (-0.39%; 95% CI, -0.56 to -0.21) after approximately 6 months of follow-up. Blood glucose monitoring did not produce better HbA1c levels than urine glucose monitoring. Fasting blood glucose levels were not different in the 2 studies that evaluated it, and quality of life was not different with blood glucose monitoring in the 2 studies that evaluated it. In one study of more than 700 patients in which it was monitored, no serious hypoglycemic episodes occurred in any patient.

Guideline for chronic constipation management

Clinical question What is the best approach to evaluating and treating chronic constipation?

Bottom line Diagnostic testing is not needed for most patients with chronic constipation. The evidence is strongest for the efficacy of psyllium, polyethylene glycol, lactulose, and tegaserod. Research is not available to support the routine use of stimulant laxatives, lubricants, stool softeners, calcium polycarbophil, bran, or any herbal products. (Level of evidence = 1a)

American College of Gastroenterology Chronic Constipation Task Force. An evidence-based approach to the management of chronic constipation in North America. Am J Gastroenterol. 2005;100:S1-S4.

Study design Systematic review

Funding Foundation

Setting Outpatient (any)

Synopsis This evidence-based guideline is based on a careful accompanying systematic review. Chronic constipation is defined as infrequent stool passage and/or difficult stool passage, incomplete evacuation, prolonged time to stool, or the need for manual maneuvers to pass stool, for at least 3 months. It is estimated that the prevalence of chronic constipation is approximately 15%; it is more common in women. Patients with alarm symptoms for cancer or bleeding should undergo a thorough diagnostic work-up. Otherwise, routine diagnostic testing is not recommended for patients with chronic constipation who have no alarm symptoms and no signs of organic disorder such as hypothyroidism after a careful history and physical examination. Regarding treatment: Of the bulking agents, psyllium increases stool frequency but data are insufficient regarding calcium polycarbophil, methylcellulose, or bran. There is insufficient evidence regarding the efficacy of stool softeners or milk of magnesia. There is good evidence that polyethylene glycol and lactulose both improve stool frequency and consistency. There are few data regarding stimulant laxatives, but the available data suggest that they are of little benefit. Tegaserod improves the frequency and consistency of stools and reduces straining, particular in younger patients. There are insufficient data regarding alternative treatments, herbal supplements, lubricants, or combination laxatives.