Impact of acupuncture for allergic rhinitis on the activity of the hypothalamus-pituitary-adrenal axis: study protocol for a randomized controlled trial

Background Patients with moderate and severe persistent allergic rhinitis (AR) have long-term physical and mental stress, leading to dysfunction of the hypothalamus-pituitary-adrenal (HPA) axis, which results in recurrence of AR. Previous research has proved acupuncture can regulate the function of the neuron-endocrine-immune system and contribute to improving the quality of life of patients with AR. This research aims to investigate the mechanism of acupuncture on the HPA axis in patients with moderate or severe persistent AR. Methods/design This randomized controlled trial aims to study the impact of acupuncture on the HPA axis of patients with moderate and severe AR. This research also aims to compare the curative effects of different treatments in three groups of patients: those receiving western medicine, western medicine and conventional acupuncture, or western medicine and mind-regulating acupuncture. We will study the therapeutic effect of acupuncture and the correlation between the changes of therapeutic indexes and experimental indexes after the treatments. Therapeutic indexes include the Visual Analog Scale (VAS) of nasal symptoms and the Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) for AR patients; experimental indexes include corticotropin releasing hormone (CRH), adreno-corticotropic hormone (ACTH), cortisol (CORT), interleukin 4 (IL-4), and interferon-γ (IFN-γ). Discussion The results of this trial will provide evidence for the influence of chronic, long-term, repeated stimulation in patients with moderate and severe persistent AR and the impact of acupuncture on the HPA axis of these patients. Trial registration Acupuncture-Moxibustion Clinical Trial Registry, AMCTR-IOR-16000009. Registered on 22 August 2016.


Background
The impact of allergic rhinitis (AR) is not limited to nasal symptoms. Based on previous studies, AR results in severe dyssomnia which causes a lack of energy during the day. This seriously affects the quality of life and work efficiency of AR patients. In adition, AR has negative impacts on the learning capability, attention, and behavior of children [1]. AR patients experience various unpleasant emotions and conditions, for example, fatigue, anxiety, tension, depression, and low sensibility [2]. A recent study about patients with persistent AR reported that 74% of 166 patients experienced psychological stress. Another study [3] found that the synthesis and secretion of cytokines such as interleukin (IL)-2, IL-6 and interferon (IFN)-γ are induced by psychological stress [4]. Psychological stress leads to imbalance of two groups of T helper cells, Th1 and Th2. The increase in Th2 causes the body to be more susceptible to allergens. Therefore, the initiation of AR includes both biological (allergen) and mental (stress, anxiety, and depression) factors.
At present, conventional medicine treatments can relieve the nasal symptoms of AR effectively. However, the psychology of AR patients is not being addressed by physicians. Attention to the psychological state of AR patients is insufficient and treatment regarding patients' psychological states is not considered during regular treatment by most ear-nose-throat doctors. This limits the therapeutic effects of the treatments [5]. Clinical research found that the negative emotions of AR patients could be relieved if the acupoints responsible for the depression are relieved and tranquilization is used at the base of regular acupoints. As well as effective relief of the clinical symptoms, quality of life was clearly improved [6]. At the same time, due to the low toxicity and side effects, compliance with treatments increases. However, current research regarding the mechanism by which acupuncture regulates AR is limited. Besides, the index used in most research is mostly restricted to the inflammatory cells and cytokines. This results in a lack of a systemic and integral research approach.
In recent years, much research has proved that acupuncture can regulate the function of the neuroendocrineimmune (NEI) system [7,8]. By stimulating the body's "selfregulation system", acupuncture enables the body to reach a dynamic balance and integration. Current research proves that the NEI system plays an important role in the pathological mechanisms of allergic diseases [9]. The NEI system of patients undergoes significant change under stress conditions. The main component of the NEI system is the hypothalamic-pituitary-adrenal (HPA) axis [10]. Under stress conditions, the body is affected by both physiological and mental factors. These changes can be long-term and excessive, leading to a series of physiological changes by interfering with the function of the neuroendocrine and immune systems. As a result, the Th1/Th2 balance is broken and the increase in Th2 induces a series of allergic diseases such as AR and asthma. This research aims to investigate the mechanism of action of acupuncture on the HPA axis in patients with moderate and severe persistent AR, and to explore the effect of acupuncture on the integral regulation of the immune system from different perspectives and multitargets. This will help to build a theoretical foundation for the therapeutic effect of acupuncture in various diseases.

Ethics and dissemination
Ethical approval for this trial has been granted by the Institutional Review Boards of Beijing University of Chinese Medicine (approval number BZYYYDX-LL-20150208), which is a central ethics committee providing approval for our two centers. Any adjustments to the scheme can only be carried out if the Ethics Committee and the volunteers give approvel after thorough communication. Written informed consent is required for all participants. The findings of the trial will be published in open access peerreviewed journals.

Trial design
This is a double-center, randomized controlled clinical trial of moderate and severe persistent AR. It has been registered in the Acupuncture-Moxibustion Clinical Trial Registry (AMCTR-IOR-16000009). This study will be carried out in Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine and Beijing Chao-Yang Hospital. The whole process will last for 13 weeks. After one week of assessment, participants will be randomly distributed into three groups to receive different treatments for 8 weeks, followed by a 4-week follow-up period. The three types of treatments are conventional acupuncture with western medicine treatment, mind-regulating acupuncture with western medicine treatment, and western medicine treatment (Fig. 1, 2).

Inclusion criteria
Eligible participants should be diagnosed with moderate or severe persistent AR according to the criteria of Allergic Rhinitis and Its Impact on Asthma (ARIA) [11] and should reach the following requirements:

Randomization and blinding
Using SAS 9.3.1 software (SAS Institute Inc., Cary, NC, USA), selected cases will be distributed in a 1:1:1 ratio to generate a randomized grouping table. Envelopes for the randomized grouping table will be prepared; the envelopes used are opaque, numbered in order, and contain the randomized serial numbers for grouping. According to the randomized serial numbers, individuals will be distributed to the observation groups and control group. Researchers in charge of data collection, data statistics, and data evaluation will be blinded from the group allocation. However, individuals being treated and the physicians will not be blinded from the group allocation due to the different interventions in this trial.

Planned interventions Acupuncture treatment
Individuals from the observation groups will undergo either the acupuncture therapy or acupuncture with conventional treatment.  Mind-regulating acupuncture treatment is done with patients in both the prone and supine positions, whereas conventional acupuncture is done only in the supine position.
Acupuncture is carried out thrice a week and lasts for 8 weeks, for a total of 24 treatments in each group.
The western medicine treatment in the two acupuncture groups is the same as that in the western medicine group.

Western medicine treatment
Individuals in the control group will receive western medicine treatment.
According to the guidelines for the treatment of AR recommended by ARIA in 2008 [13], individuals in the control group will receive 2-4 weeks of intranasal corticosteroids, H1-antihistamines, or leukotriene receptor antagonists; after this, a specialized ENT examination will be repeated. An otolaryngologist will adjust the dosage or drug schedule according to the ENT findings, and treatments will be continued. One treatment course will last for 8 weeks.

Outcomes
Therapeutic effect: 1. VAS of nasal symptoms score [14] The scale includes overall nasal symptoms and differentiated nasal symptoms. The highest score for each section is 10, representing a symptom that is unbearable; the lowest score for each section is 0, representing a symptom with no influence. VAS score is accurate to one decimal place. It is used to evaluate the influence of overall nasal symptoms and differentiated nasal symptoms over the past week.
Data will be collected before the start of treatment (the baseline assessment) and at the end of each week during the treatment and follow-up periods.

Rhinoconjunctivitis Quality of Life Questionnaire
score [15] The Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) includes 24 questions in seven sections: activity, sleeping, symptoms unrelated to nose and eyes, actual problems, nasal symptoms, ocular symptoms, and emotion. The score for each question is divided into seven levels: 0 = no influence, 1 = almost no influence, 2 = some influence, 3 = moderate influence, 4 = bad influence, 5 = worse influence, 6 = worst influence. The score is calculated separately in each section and the total score of these seven sections is considered as the RQLQ score. The highest possible score is 144. The scale is used to evaluate the influence of rhinitis symptoms on patient quality of life.
Data will be collected before the start of treatment (the baseline assessment) and at the end of each week during the treatment and follow-up periods.
Data will be collected before the start of treatment (the baseline assessment), at the end of treatment, and 4 weeks after the treatment.

Adverse events
Information on adverse events will mainly depend on the conscious feedback of individuals. Prior guidance is necessary for all volunteers. If an adverse event occurs, physicians will check the patients' condition immediately and decide if any necessary examinations and treatments will be carried out. For serious adverse events, the trial will be interrupted immediately and proper steps will be taken, and detailed information on incidents will be recorded at the same time.

Sample size
This study is exploratory research designed to investigate the mechanism of acupuncture treatment for AR patients. With reference to the first stage of the clinical trial in the national drug register published in 2005, also based on a preliminary study and other research findings, the required sample size is 90; taking into account a 20% drop-out rate, a total of 108 cases will be recruited. Dongzhimen Hospital and Beijing Chaoyang Hospital are each responsible for 50% of recruitment for the clinical study. Another 36 healthy volunteers will be recruited as the control group, for a total of 144 cases.

Statistical analysis
Data from this clinical trial will be analyzed using SPSS version 21.0 software (released 2012, IBM Corp., Armonk, NY, USA). Demographic (age, sex, course, family history, et al.) and clinical data will be used as the baseline assessment to compare the two groups. The main and second indexes of therapeutic effects will be measured as mean ± standard deviation. Differences before and after the treatment in each group will be compared by paired t-test. ANOVA will be used in the comparison between groups. Count data will be measured by constituent ratio while chi-square test or non-parametric test will be used in the comparison between groups. P<0.05 indicates the difference is statistically significant.

Discussion
AR has become a global and intractable disease. Besides negative impacts on patients' quality of life, it results in various kinds of diseases which may cause the loss of working ability and life. Although the symptoms can be relieved effectively by various topical or oral drugs, susceptibility to the disease cannot be changed. Specific immunotherapy can relieve the allergic symptoms, but long-term treatment always results in poor compliance [16]. Acupuncture, on behalf of traditional treatments, reflects the emphasis of TCM on "mind-regulation". In all kinds of diseases, especially physical and mental disorders, treatments which emphasize both a patient's physiological and mental state, play an important role. Recent research proves that [17] AR is a physical and mental disorder, being closely related to social psychological factors. AR patients, especially those with moderate and severe disease, are likely to have mental and behavior problems due to the chronic and unstable symptoms, continuous and unsuccessful treatments, accumulated medical expenses, and effects on their social function. Furthermore, a patient's mental and behavior problems may aggravate their illness [18]. As a result, a vicious cycle is formed.
In 2001, WHO organized a discussion, attended by Otolaryngology experts from around the world, on the impact of AR on asthma and the concept of "one airway, one disease" has been proposed. Except for differences in their clinical symptoms, AR and asthma are similar in various aspects, such as pathogenic and pathological changes [19]. At present, the HPA axis has become the focus in research on the mechanisms involved in AS [20]. Some scholars feel that the HPA axis of AR patients is likely to be activated. After stimulation of patients' nasal cavities by allergens, the detection of ACTH and cortisol in the peripheral blood circulation indicates that AR can activate the HPA axis [21]. However, by considering the complexity of the pathogenic mechanism of AR, the influence of chronic, long-term, repeated stimulation of the HPA axis of patients with moderate or severe persistent AR is unclear.
On the basis of a large number of references and related research, a hypothesis is suggested that patients with moderate or severe persistent AR undergo a longterm change in stress status both physically and mentally. High stimulation activates the HPA axis continuously, with excessive secretion of hormones resulting in selective inhibition of Th1 cells. The balance tends to move towards the humoral immune system mediated by Th2 and this increases patients' susceptibility. On the other hand, long-term activation of the HPA axis may induce HPA axis exhaustion and lead to its dysfunction, resulting in lost control and limitation of the allergic inflammation. This may be one of the reasons for AR recurrence. Acupuncture can relieve patients' nasal symptoms and modulate their psychological state by regulating hormones and cytokines of the HPA axis. This moderates the functions of the NEI system to relieve the allergic inflammation of AR. However, this RCT is an exploratory study with limited experience. Therefore, the sample size, outcome evaluation items, and follow-up pattern should be improved in the future.

Trial status
Ongoing.