J Acupunct Meridian Stud 2017;10(4):290e293

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Journal of Acupuncture and Meridian Studies

journal homepage: www.jams-kpi.com

CLINICAL CASE REPORT

Acupuncture for Management of Type 2

Diabetes Mellitus in a Patient with
Myasthenia Gravis: A Case Report
Yun Jin Kim*

Faculty of Chinese Medicine, Southern University College, Johor, Malaysia

Available online 18 May 2017

Received: Feb 23, 2017 Abstract

Revised: May 11, 2017
Accepted: May 12, 2017
KEYWORDS
acupuncture;
myasthenia gravis;
type 2 diabetes mellitus
Myasthenia gravis (MG) is an acquired disease of the neuromuscular junctions character-
ized by muscular weakness and fatigue, with a prevalence of 50e125 cases per million
population in western countries. In men, it usually appears after the age of 60 years,
while in women, it usually appears before the age of 40 years. Long-term immunosuppres-
sion with corticosteroids is the mainstay treatment for patients with MG; however, the
use of corticosteroids is a well-documented risk factor for type 2 diabetes mellitus, which
has also been reported in steroid-treated patients with MG. Here, a case of type 2 dia-
betes mellitus in a patient with MG who underwent 105 sessions of acupuncture delivered
over 6 months is reported. After acupuncture treatment, the patients fasting plasma
glucose and hemoglobin A1c levels, as well as the score on the Hamilton Depression Rat-
ing Scale, were decreased. Furthermore, no adverse effects were observed. The findings
in this clinical study are encouraging and provide evidence supporting the effectiveness
of acupuncture in reducing type 2 diabetes mellitus in a patient with MG.

1. Introduction fatigue. Its reported prevalence is 50e125 cases per million

Myasthenia gravis (MG) is an acquired disease of the neuro-
muscular junctions characterized by muscular weakness and
* Corresponding author. Faculty of Chinese Medicine, Southern
University College, Jalan Selatan Utama, Off Jalan Skudai,
Skudai, Johor 81300, Malaysia.
E-mail: yjkim@sc.edu.my.
pISSN 2005-2901 eISSN 2093-8152
http://dx.doi.org/10.1016/j.jams.2017.05.003
2017 Medical Association of Pharmacopuncture Institute, Publishing services by Elsevier B.V. This is an open access article under the CC
BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
population in western countries, and w25,000 persons in the
United States are affected [1]. In men, the condition usually
appears after the age of 60 years, while in women, it usually
appears before the age of 40 years [2,3]. Patients with MG
experience weakness, with abnormally rapid fatigue of the
muscles that move the extremities, face, eyelids, and eyes,
and the muscles required for swallowing and respiration.
Involvement of these last two groups of muscles can be fatal
if severe and untreated.
Acupuncture for Management of Type 2 Diabetes
MG is an autoimmune condition in which the post-
synaptic membrane of the neuromuscular junction un-
dergoes an antibody-mediated alteration and acetylcholine
receptors (AChRs) are destroyed [4], which is believed to
occur when anti-AChRs bind to postsynaptic receptor sites
[5]. Long-term immunosuppression with corticosteroids is
the mainstay treatment for patients with MG, but the use of
corticosteroids is a well-documented risk factor of type 2
diabetes mellitus, which has also been reported in steroid-
treated patients with MG [6,7].
Here, we report a case of type 2 diabetes mellitus in a
patient with MG, who underwent 105 sessions of acupunc-
ture treatment over a period of 6 months. The patients
fasting plasma glucose and hemoglobin (Hb) A1c levels, as
well as the score on the Hamilton Depression Rating Scale,
were decreased, and no adverse effects were observed.
Such findings are encouraging and support the effectiveness
of acupuncture in reducing type 2 diabetes mellitus in a
patient with MG.
2. Case Report
We report a 58-year-old man who was diagnosed with MG in
1986, and developed type 2 diabetes mellitus in 2015. He
was receiving long-term immunosuppressive therapy for MG
comprising prednisone at a daily dose of 10 mg and
azathioprine at a daily dose of 50 mg. After being diagnosed
with type 2 diabetes mellitus, the patient began taking
metformin at a daily dose of 500 mg.
The Institutional Review Board and Medical Research
Board, Southern TCM Centre, Southern University College,
Johor, Malaysia, approved this retrospective, observational
study. The requirement for the patients approval or
Table 1 Comparison of pre- and post-treatment fasting plasma glucose levels (mg/dL)
Baseline 1 mo 2 mo 3 mo
133  9.7 113  7.1 110  6.5 108  3.9*
Values represent means  standard errors of the mean.
A lower score indicates a better outcome.
*p < 0.05.
Table 2 Comparison of pre- and post-treatment HbA1c levels (%)
Baseline After 1 mo 2 mo 3 mo
8.36  0.29 8.33  0.98 8.16  0.51 7.68  0.28
Values represent means  standard errors of the mean.
A lower score indicates a better outcome.
*p < 0.05.
Table 3 Comparison of pre- and post-treatment scores on the Hamilton Depression Rating Scale
Baseline 1 mo 2 mo 3 mo
18.45  1.68 12.38  1.09 12.28  0.56 11.74  2.51
Values represent means  standard errors of the mean.
A lower score indicates a better outcome.
*p < 0.05.
291
informed consent for the review of his medical records was
waived (SUC_STCM_2015/1).
The following seven acupoints are used for acupuncture
for type 2 diabetes mellitus: Pishu (BL20), Shenshu (BL23),
Zusanli (ST36), Sanyinjiao (SP6), Hegu (LI4), Quchi (LI11),
and Taichong (LR3). The acupoints used in this study were
selected based on various scientific studies of acupuncture
for the management of patients with type 2 diabetes mel-
litus and its complications [8e10].
The acupuncture needles (Sterile disposable stainless
acupuncture needle, size: 0.3 mm  45 mm; Jia Jian
Medical San. Bhd. Reg. No.: 20060095) were inserted into
the muscle layer. After the arrival of the needling sensation
of de qi, the seven acupoints underwent electric stimula-
tion (SDZ-II Model, Serial No.: 2270611. Suzhou Medical
Appliance Factory, Suzhou, China). The intensity of stimu-
lation was maintained within the patients tolerance by
using the DD wave (spacing-wave frequency is 1/5 of den-
sity frequency, density-wave frequency adjustable in
5e100 Hz. Spacing-wave time is 5 seconds, density-wave
time is 10 seconds), and the needles were kept in place for
30 minutes. The acupuncture treatment was given three
times per week for 6 months.
Before acupuncture, the patients fasting plasma
glucose (FPG) and HbA1c levels, as well as his Hamilton
Depression Rating Scale (HDRS) score, were measured, and
the values were used to establish a baseline. During
acupuncture, these parameters were monitored monthly.
The plasma samples were investigated at Pathlab Labora-
tory (M) Sdn. Bhd (37363-K) in the Taman Perling branch,
Nusajaya, Johor, Malaysia, and the HDRS score was deter-
mined at Southern TCM Centre, Southern University. All
data collected during the 6 months were evaluated to
4 mo 5 mo 6 mo
105  3.2* 102  1.8* 101  4.8*
4 mo 5 mo 6 mo
7.55  0.77 6.89  0.85 6.67  0.39*
4 mo 5 mo 6 mo
11.62  1.26* 10.68  0.68* 8.87  1.23*
292
determine the effect of acupuncture in the management of
type 2 diabetes mellitus in a patient with MG.
Table 1 presents the mean FPG levels at baseline and at
each month during the treatment. After 3 months of
acupuncture, the FPG level decreased significantly
(p < 0.05) in comparison with the baseline. Table 2 presents
the mean HbA1c levels at baseline and at each month
during treatment. HbA1c level decreased significantly
(p < 0.05) after 6 months of acupuncture. HbA1c level was
8.36  0.29% at baseline and reduced to 6.89  0.85% at the
end of 6-months treatment. Table 3 presents the mean
HDRS scores at baseline and at each month during treat-
ment. HDRS score was highest before acupuncture and was
significantly lower (p < 0.05) after 4-months acupuncture.
3. Discussion
MG is the most common disorder of neuromuscular trans-
mission; is characterized by muscle weakness and fatigue;
is B-cell mediated; and is associated with antibodies
directed against AChR, muscle-specific kinase, lipoprotein-
related protein 4, or agrin in the postsynaptic membrane at
the neuromuscular junction [11]. Although corticosteroids
are often used in the treatment of patients with MG, their
use is associated with an increased risk of diabetes. Long-
term corticosteroid use may alter glucose production and
regulation, leading to hyperglycemia. Corticosteroids also
interfere with insulin signaling in skeletal muscle cells. This
means that at high doses, patients, especially those with
impaired glucose tolerance, are at an increased risk for
developing steroid-induced diabetes [12].
In acupuncture prescription, the Back-Shu acupoints of
Pishu (BL20) and Shenshu (BL23), in combination with
Zusanli (ST36), are thought to regulate the functions of the
lungs, spleen, and kidneys, nourish Yin, and produce body
fluid. Moreover, the Hegu (Li4), Sanyinjiao (SP6), and
Zusanli (ST36) acupoints, in combination with bleeding at
the Jing acupoints, are thought to circulate Qi, activate
blood, and disperse blood stasis. In particular, acupuncture
at the Zusanli (ST36), Quchi (LI11) and Sanyinjiao (SP6)
acupoints can decrease plasma fibrinogen so as to reduce
blood coagulation and improve blood circulation [13]. The
Taichong (LR3) and Zusanli (ST46) acupoints can be used to
activate or deactivate brain areas related to movement,
emotion, and analgesia and to decrease depression in pa-
tients with type 2 diabetes mellitus [14]. Combinations of
various acupoints can be used to regulate Yin and Yang,
nourish Yin, and activate blood without damaging the anti-
pathogenic ability so as to regulate the metabolism of blood
sugar, promote blood circulation, and decrease blood sugar
[15]. McGarry [16] showed that electroacupuncture at the
Zusanli (ST36) acupoint, by stimulating the cholinergic
nerves, which, in turn, stimulated the expression of insulin-
signaling proteins, induced a hypoglycemic response in
streptozotocin-induced diabetic rats.
Several studies have provided evidence that patients
with depression have an increased risk of developing type 2
diabetes mellitus [17,18]. A recent epidemiological study of
90,686 participants found that depression was more preva-
lent in people with diabetes, regardless of whether or not
they had been diagnosed as having the disease [19]. In
Y.J. Kim
addition, in 2010, a review of the literature on the influence
of acupuncture on insulin resistance was published [20]. In
that review, the authors analyzed 234 articles and
concluded that evidence, although limited, did confirm the
efficacy of acupuncture in patients with insulin resistance.
Also, no studies looking at the short-term or long-term ef-
fects of acupuncture for insulin resistance have been pub-
lished. Thus, based on this clinical case report, the authors
suggest that future studies are needed to investigate in
larger populations of patients with type 2 diabetes mellitus,
especially those who also have MG, the short-term and long-
term effects of acupuncture, as well as any beneficial effect
that might be achieved by including additional acupuncture.
Acupuncture carries several potential advantages, such
as low cost, few complications, and the possibility of
personalized treatment. Acupuncture is also a safe inter-
vention in the hands of competent practitioners [21].
Yamashita et al [22] prospectively evaluated 55,291
acupuncture treatments administered by acupuncturists
with medical training and documented only 64 adverse
events (0.12%). All of those adverse events were minor,
with the most common being bruising, dizziness, perspira-
tion, discomfort, and dermatitis [22]. Such results suggest
that acupuncture is a safe and effective therapy for
treating type 2 diabetes mellitus in patients with MG,
although its mechanism of action remains a matter for
speculation.
Disclosure statement
The authors declare that they have no conflicts of interest
and no financial interests related to the materials in this
manuscript.
Acknowledgments
The authors of this case report received no specific grants
from funding agencies in the public, commercial, or not-
for-profit sectors.
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