Evaluating combined acupuncture and antiresorptive therapy in Chinese women with postmenopausal osteoporosis: a systematic review and network meta-analysis

This is the authors' abstract. We don't add key points for this paper.

Background: Postmenopausal osteoporosis (PMOP) is a common metabolic disorder in middle-aged and older women, leading to fractures, disability, and increased mortality. Current treatments include bisphosphonates (BPs), calcitonin (CT), vitamin D (VD), and acupuncture (Acu), often used in combination, but comparative evidence on different combined strategies remain limited. Objective: To systematically compare the efficacy and safety of acupuncture combined with various medications for PMOP, supporting evidence-based clinical decisions. Methods: We searched eight databases from inception to April 11, 2026 for randomized controlled trials (RCTs) evaluating acupuncture plus pharmacotherapy for PMOP. Primary outcomes included lumbar spine (LS) and femoral neck (FN) bone mineral density (BMD), clinical efficacy, Traditional Chinese Medicine (TCM) syndrome scores, and Visual Analog Scale (VAS) pain scores. Secondary outcomes were procollagen type I N-terminal propeptide (PINP), C-terminal telopeptide (CTX), estradiol (E2), alkaline phosphatase (ALP), and osteocalcin (OCN). A Bayesian network meta-analysis was performed, ranking treatments by surface under the cumulative ranking curve (SUCRA). Results: We included 112 RCTs (9, 908 patients, 83 treatment strategies). For LS-BMD, Calcitriol (Cal)_Electroacupuncture (ElecAcu) ranked highest. For FN-BMD, CT_VD_Traditional Chinese Medicine (TCM)_Fire dragon moxibustion (FDMox) (without BP) and CT_VD_BP_TCM_Acu (with BP) were best. TCM_Acu showed the best clinical efficacy. For TCM syndrome total score, CT_VD_ Du-moxibustion (DuMox) ranked lowest. For low back pain, TCM_Acu (without BP) and CT_VD_BP_Acu_Moxibustion (Mox) (with BP) were best. CT_VD_BP_Acu_Point Application Therapy (Pat) ranked lowest for VAS. CT_VD_BP_Acupoint injection (AcuInj) produced the lowest PINP, CT_VD_TCM_Acu the lowest CTX, and CT_VD_BP_TCM_Acupoint catgut embedding (ACE) the highest E2. For ALP, CT_VD_BP_Acu ranked lowest with BP, and CT_VD_Mox highest without BP. For OCN, CT_VD_Mox ranked highest without BP, and CT_VD_BP_TCM_Acu_Mox highest with BP. Conclusion: Acupuncture combined with pharmacotherapy offers differential benefits across efficacy outcomes in PMOP. However, fracture data were nearly absent (only one trial reported two hip fractures) and follow-up was short (≤12 months), limiting any inference on fracture prevention. Treatment selection should be individualized based on therapeutic priorities and patient characteristics, supporting personalized integrative management strategies. Systematic review registration: https://www.crd.york.ac.uk/PROSPERO/, identifier CRD420251233374.