Aromatase inhibitors (AIs), such as exemestane, anastrazole, and letrozole, are standard treatments for the reduction of recurrence of breast cancer (BC) in postmenopausal women and hormone receptor–positive patients. However, their use is associated with treatment-limiting arthralgias, which can occur in up to one-quarter of patients and have been associated with nonadherence. Nonpharmacologic modalities that can relieve this pain without exposing patients to the side effects of drug therapy would be ideal.
Past efforts to explore the place of acupuncture in the management of AI-induced arthralgia have been limited to four meta-analyses, which did not take into account the placebo effect nor did they include the Chinese literature.
A recent meta-analysis aimed to clarify the clinical and placebo effects of acupuncture with respect to those of a control intervention in patients with AI-induced arthralgias. In this comprehensive meta-analysis, investigators from the Republic of China conducted a literature search, which included five English databases (PubMed, Web of Science, Embase, Springer, and Cochrane Library) and four Chinese databases (China National Knowledge Infrastructure Database, SinoMed, VIP, and Wanfang). Studies were included if they involved participants aged 18 years or older; patients diagnosed with BC based on pathology, cytology, or histological features; and patients taking AIs for greater than 1 month.
Seven articles representing a total of 603 patients were included in the meta-analysis. The average age of study participants ranged from 41 to 85 years and they had stages I to III BC. The interventions that were compared included acupuncture (auricular acupuncture, body acupuncture), sham acupuncture, drugs, or no treatment. Pain was assessed by the Brief Pain Inventory (BPI) in five studies, by the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) in four studies (but only two studies were included in the final analysis because of failure to report specific WOMAC results), and by a Visual Analog Scale (VAS) in two studies; this latter test was not included in the meta-analysis due to inconsistencies between the methodologies utilized between the studies. The studies also included various performance measures. The risk of bias was assessed for all of the studies.
The researchers found that for patients with AI-induced arthralgias, acupuncture significantly improved pain-related interference scores, pain-severity scores, and worst-pain scores on the BPI compared with drugs and no treatment (e.g., waitlist control group). However, there was no difference in pain-related interference scores, pain severity scores, or worse-pain scores as assessed by BPI or for pain scores, stiffness scores, functional scores, and normalized scores on the WOMAC between acupuncture and sham acupuncture, which is considered a placebo effect. The authors expressed caution in interpreting these results as there was great heterogeneity among the methods of sham acupuncture employed. Some used sham needles that did not penetrate the skin while other used minimally invasive needles.
There were no severe adverse reactions identified in any of the acupuncture studies. Minor adverse events included bruising, presyncope, and pain; however, not all studies reported on this parameter.
As we search for safer pain-management alternatives to opioids and nonsteroidal anti-inflammatory agents, pharmacists can suggest the use of acupuncture as a benign, useful intervention for the relief of AI-induced arthralgias in BC patients.
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