Moxibustion combinations for diabetic peripheral neuropathy: a network meta-analysis of 40 randomised trials

Objective Moxibustion, an external treatment used in traditional Chinese medicine, is increasingly applied to diabetic peripheral neuropathy (DPN). We compared the effectiveness of the principal moxibustion-containing treatment combinations for this condition. We searched for randomised controlled trials (RCTs) available by 14 April 2026. Sources were PubMed, EMBASE, the Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI), Wanfang Medical Database and VIP Database. The resulting network meta-analysis (NMA) covered moxibustion (MOXI) and combinations with acupuncture therapy (ACU), massage therapy (MT), internal herbal medicine (IHM), external herbal medicine (EHM) or conventional treatment (CT). Outcomes included common peroneal and median motor nerve conduction velocity (MNCV), sensory nerve conduction velocity (SNCV), Toronto Clinical Scoring System (TCSS) score and markedly effective rate. Random-effects models in Stata MP 17.0 generated mean differences (MDs) and risk ratios (RRs). Evidence certainty was graded with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. Results Forty studies involving 3,718 participants were included. Moderate-certainty evidence favoured MOXI+EHM over CT for common peroneal MNCV (MD = 6.14 m/s, 95% CI 3.82 to 8.46). Evidence also favoured MOXI+EHM for median MNCV (MD = 6.35 m/s, 95% CI 2.35 to 10.36). The corresponding estimate for common peroneal SNCV was MD = 8.44 m/s (95% CI 4.80 to 12.08). For median SNCV, MOXI+ACU outperformed CT (MD = 6.61 m/s, 95% CI 1.29 to 11.92). MOXI+EHM showed a similar effect (MD = 4.32 m/s, 95% CI 1.01 to 7.63). Certainty for this outcome ranged from moderate to very low. Moderate-certainty evidence also showed that MOXI+EHM reduced TCSS scores (MD=-2.55 points, 95% CI -3.81 to -1.30). MOXI+EHM (RR = 1.74, 95% CI 1.27 to 2.40) and MOXI+ACU (RR = 1.59, 95% CI 1.05 to 2.41) increased the markedly effective rate versus CT. Conclusion Moderate-certainty evidence suggests that MOXI+EHM may improve nerve conduction, clinical symptoms and signs, and the markedly effective rate in patients with DPN. Moxibustion-based combination therapy may therefore offer a useful adjunct to conservative DPN management, although the findings require confirmation in rigorous trials. Systematic review registration https://www.crd.york.ac.uk/PROSPERO/view/CRD420261444059 , identifier CRD420261444059.