Stimulated by Gyeltshen et al 2025.[1]
IF – impact factor
EiC – editor in chief
SLR – straight leg raising (the most famous test for sciatica, but not a terribly good one)– key to acronyms
This is a somewhat smaller trial (n=70) than the last one I highlighted on sciatic (Acupuncture for chronic sciatic 2024), but it comes from Bhutan (which is a first for this blog), and it has an acronym – ACUWARM. It is an open pragmatic non-inferiority trial of warm acupuncture compared with oral gabapentin and is published in the Journal of Evidence-Based Integrative Medicine (IF 3.6). The latter is a Sage journal with an editorial board principally from USA. The EiC is an allergist and immunologist with an interest in integrative medicine. I did not see anyone on the wider editorial board that I recognised from the field of acupuncture apart from the infamous EE.
The trial was performed in the 2 biggest hospitals in Thimphu, which is the capital of Bhutan. Sciatica patients were recruited from the orthopaedic department of the allopathic hospital (Jigme Dorji Wangchuck National Referral Hospital). Jigme Dorji Wangchuck (1929–1972) was the 3rd king of Bhutan… we are now on the 5th.
The name Dorji caught my eye since it is the first name of the first author of this paper, the second name of the second and corresponding author, and is in the name of the biggest hospital in Bhutan. Dorji (often written Dorgee in Tibetan contexts) derives from the Sanskrit word Vajra, which literally means thunderbolt (the weapon of the god Indra) and diamond (indestructible, pure, and enduring).
Sciatica was defined as unilateral radiating leg pain below the knee and a positive SLR or at least one neurological deficit. Patients with sciatica were randomised to warm acupuncture or gabapentin, and the former group were sent to the National Traditional Medicine Hospital, which is 3 km away from the National Referral Hospital, although in the rest of Bhutan, allopathic and traditional hospitals are generally co-located.
Warm acupuncture was applied 3 times a week for 3 weeks. Sessions lasted 20 to 70 minutes and consisted of needle insertion followed by application of moxibustion to the handles of the needles. The latter is the usual meaning of the term warm acupuncture, although it is not defined in the paper. The points used were BL23, BL25, BL54, GB30, BL40, GB34, BL57, GB39, BL60, plus tender points. Presumably these were on the affected side, but this is not stated.
Gabapentin was prescribed by the orthopaedic surgeon at the allopathic hospital at a dose of 300mg twice a day, which seems rather inadequate as a dosing regimen. I suppose it could have been a starting dose, with some degree of escalation, but there is no detail concerning this.
Why non-inferiority? Well, gabapentinoids are often used in sciatica, despite this not being a licenced indication. I remember passing one of the main lecture halls at the 2010 World Congress of Pain in Montreal. I popped into the back to listen as I had heard sciatica being mentioned. The presenter was urging the audience to accept his assertion that sciatica was a form of neuropathic pain. I thought to myself… no it isn’t, and I know where this is going! Those were the days of the massive push to expand the market for the underperforming anti-epileptic gabapentin.
Anyway, thanks to the references in the paper, I discovered a head-to-head trial of gabapentinoids in sciatica.[2] The trial was a crossover with one week washout period separating 8 weeks of one or the other drug. Gabapentin at 400-800mg 3 times a day was compared with pregabalin at 150-300mg twice a day. The trial was stopped at the halfway point (n=18) because gabapentin was clearly superior and there were significantly more side effects associated with the pregabalin. This paper in JAMA Neurology (IF 21.3) concluded that both drugs were efficacious despite the absence of a placebo control, but that gabapentin should be used first in adults with chronic sciatica. The result is rather curious considering both drugs bind to the same α2δ subunit of voltage-gated calcium channels (reducing release of excitatory neurotransmitters) and only seem to differ in terms of pharmacokinetics, with pregabalin having substantially greater bioavailability.
The team from Bhutan also referenced a systematic review of the same gabapentinoids in sciatica.[3] This review was published in the journal Atención Primaria (IF 1.6), which is the official journal of the Spanish Society of Family and Community Medicine. This review included 8 trials and found one favouring gabapentin over placebo but concluded that there was clear evidence for a lack of effectiveness of either gabapentin or pregabalin in sciatic and that neither should be used routinely.
So, how did warm acupuncture do against a rather small dose of gabapentin? Mostly it was better, but not all the results were consistent in this regard, and the follow-up was relatively limited. The authors concluded that warm acupuncture was non-inferior, and they are probably right; however, there are some discrepancies in the reporting of results, so I have contacted one of the Dorji’s and I am keeping my eye out for a thunderbolt in reply.
Sometime later…
I am happy to say that I got a reply from the corresponding author in Bhutan, who is also the managing editor of the Bhutan Sorig Journal, which is devoted to traditional medicine. He sent me a corrected figure, confirmed that warm acupuncture refers to moxa burned on the handles of acupuncture needles, and clarified that the gabapentin dose used in the trial is the standard dose available in Bhutan. Many thanks to Dr Thinley Dorji for the rapid responses and information.
References
1 Gyeltshen D, Dorji T, Tenzin K, et al. Efficacy and Safety of Warm Acupuncture Compared to Gabapentin for Pain Management in Patients with Sciatica in Bhutan: A Randomized Controlled (ACUWARM) Trial. J Evid-Based Integr Med. 2025;30:2515690X251355513. doi: 10.1177/2515690X251355513
2 Robertson K, Marshman LAG, Plummer D, et al. Effect of Gabapentin vs Pregabalin on Pain Intensity in Adults With Chronic Sciatica: A Randomized Clinical Trial. JAMA Neurol. 2019;76:28–34. doi: 10.1001/jamaneurol.2018.3077
3 Giménez-Campos MS, Pimenta-Fermisson-Ramos P, Díaz-Cambronero JI, et al. A systematic review and meta-analysis of the effectiveness and adverse events of gabapentin and pregabalin for sciatica pain. Aten Primaria. 2022;54:102144. doi: 10.1016/j.aprim.2021.102144
Declaration of interests MC
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