Treatment effects and safety of Chinese herbal medicine in gastroesophageal reflux disease: a systematic review of randomized controlled trials and a network meta-analysis with component analysis

Background Gastroesophageal reflux disease (GERD) is commonly treated with proton pump inhibitors (PPIs) despite their adverse effects and risk of recurrence. Chinese herbal medicine (CHM) has long been used to alleviate reflux-related symptoms and reduce relapse through multi-component and multi-target strategies. To evaluate the efficacy and safety of CHM for GERD and identify key botanical drugs contributing to therapeutic effects using a component-level analytical framework. Methods English and Chinese databases were screened for relevant articles up to 15 April 2026. Eligible randomized controlled trials (RCTs) compared CHM with biomedicine. A meta-analysis was performed using RevMan 5.4 software, and the risk of bias assessed using Cochrane Risk of Bias two tool. A component-level contribution analysis based on component network meta-analysis (CNMA) framework and core-pattern network analysis were used to quantify individual botanical drug contributions and co-prescription structures. Results Twenty randomized controlled trials involving 2,246 patients with GERD were included. Pairwise meta-analysis showed that CHM was superior to PPIs in clinical efficacy (odds ratio: 4.13, 95% confidence interval: 2.73–6.25) and symptom relief (standard mean difference: 0.71, 95% confidence interval: 0.49–0.94), with lower recurrence rates and equivalent safety. Network meta-analyses identified several CHM formulas with favorable effects relative to PPIs. Component-level contribution analyses identified varying associations among botanical drugs. Core-pattern analysis identified Pinelliae rhizoma as a highly connected botanical drug. Conclusion This study presents the first component-level analysis of CHM prescriptions for GERD, suggesting improvements in clinical efficacy and recurrence control. By integrating prescription patterns with evidence-based pharmacology, our findings provide insights into multi-target CHM strategies and support the potential of CHM to strengthen the esophagogastric barrier and reduce long-term PPI dependence. Trial registration The study was registered on PROSPERO, registration number CRD42024612778.