Comparative efficacy and safety of Chinese medicine external therapies for diarrhea-predominant irritable bowel syndrome: a systematic review and network meta-analysis.

BACKGROUND: Diarrhea-predominant irritable bowel syndrome (IBS-D) is a chronic functional gastrointestinal disorder that significantly impairs patients' quality of life. While various Chinese medicine external therapies (CMETs) have been widely utilized, their relative superiority and safety remain poorly defined. This study aims to evaluate and rank the comparative efficacy and safety of different CMETs for IBS-D. METHODS: We systematically searched PubMed, Embase, The Cochrane Library, and CNKI from inception to March 2026 for randomized controlled trials (RCTs) evaluating CMETs for IBS-D. The primary outcomes were clinical total effective rate (TER) and the IBS Severity Scoring System (IBS-SSS). Secondary outcomes included IBS-Quality of Life (IBS-QOL), abdominal pain scores, and adverse events (AE). A frequentist network meta-analysis (NMA) was performed using the netmeta package in R software. Interventions were ranked using P-scores. Global and local inconsistency were assessed via Q-statistics and the node-splitting method. RESULTS: Twenty-two RCTs involving 11 distinct interventions were included. For the clinical total effective rate (TER), moxibustion (P-score = 0.8600) and tuina (P-score = 0.7130) emerged as the top-ranked interventions compared with Western medicine (WM) and placebo. Regarding symptom reduction (IBS-SSS) and abdominal pain relief, electroacupuncture (EA) (P-scores = 0.8854 and 0.8591, respectively) demonstrated superior efficacy over other modalities. Acupoint application combined with WM was found to be the most effective for improving quality of life (P-score = 1.0000). Safety analysis indicated that transcutaneous electrical acustimulation (TEA) (P-score = 0.8108) and placebo had the lowest risk of adverse events. Node-splitting analysis did not indicate statistically significant inconsistency; however, the findings should be interpreted cautiously because formal sensitivity analyses excluding high-risk studies were not feasible for all outcomes. CONCLUSION: Chinese medicine external therapies may provide beneficial adjunctive or complementary options for patients with IBS-D. Moxibustion ranked highest for study-defined TER, whereas EA ranked highest for IBS-SSS and abdominal pain reduction. However, CINeMA assessment indicated low or very low confidence in several estimates; therefore, these rankings should be interpreted cautiously. SYSTEMATIC REVIEW REGISTRATION: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=1324349, identifier CRD420261324349.