Moxibustion for rheumatoid arthritis: Clinical evidence, syndrome-specific application and mechanisms (a narrative review)

Rheumatoid arthritis (RA) is a chronic autoimmune disease. It causes synovial inflammation, pannus formation and damage to cartilage and bone. Disease-modifying antirheumatic drugs (DMARDs) and biologic agents are the main treatment, but long-term use often brings adverse events, loss of response and high cost. Moxibustion is a non-invasive heat therapy from traditional Chinese medicine (TCM). This narrative review looks at recent clinical evidence, pattern-based use and proposed mechanisms of moxibustion in RA. Meta-analyses and randomized trials report that moxibustion, alone or with DMARDs, reduced joint pain (VAS), morning stiffness, tender and swollen joint counts, disease activity scores (DAS28, SDAI, CDAI) and disability (HAQ). Pooled analyses also report lower CRP, ESR and rheumatoid factor (RF). Treatment is usually matched to the TCM pattern, mainly Cold-Dampness Obstruction and Liver-Kidney Deficiency. Trials used ginger- or salt-separated moxibustion, wheat-grain direct moxibustion and an automated sparrow-peck device, mostly at Zusanli (ST36), Shenshu (BL23) and Ashi points. The proposed mechanisms fall into four groups. The first is lower pro-inflammatory cytokines and angiogenic signals (TNF-α, IL-1β, IL-6, IL-17, HIF-1α/VEGF). The second is better bone remodeling through the OPG/RANKL balance and Wnt/β-catenin signaling. The third is a change in gut microbiota along the gut-brain-joint axis. The fourth is an effect on neuro-endocrine-immune pathways, including the cholinergic anti-inflammatory reflex, 5-HT, β-endorphin and IGF-1. The results look promising. Still, most trials are small, single-center, unblinded and short, so larger sham-controlled trials are needed.