# Bee Venom Acupuncture in Traditional Korean Medicine: A Review of Clinical Practice Guidelines
## 6 Discussion and Future Directions  
This study aimed to investigate clinical recommendations related to BVA within CPGs in TKM. Our comprehensive review identified 18 CPGs containing 30 specific BVA recommendations across various diseases, primarily musculoskeletal and neurological disorders. The CPGs recommended BVA as a standalone therapy or in combination with other TKM modalities (AT, EA, or HM). The acupoints used for BVA included a high proportion of Ashi points but varied depending on the targeted disease. The regimen specifications varied across CPGs, with a dose of 0.05 to 0.2 cc, concentration ranging from 3000:1 to 20,000:1, treatment frequency (typically around two to three sessions per week), and duration, while others still lacked specific treatment protocols. Most CPGs recommended BVA therapy based on RCTs to demonstrate higher-quality evidence. However, the level of evidence varied, with most falling into the moderate to low levels. No high-quality evidence was found. The grades of recommendation for BVA also varied, with most being graded as B or C, indicating that BVA is generally considered advisable or potentially beneficial in clinical practice, but not strongly endorsed as a first-line treatment. Notably, the assessment of factors such as potential benefits, harms, availability in clinical practice, medical costs, and patient preferences varied considerably across the guidelines, with only a few CPGs providing comprehensive evaluations of all these aspects. Our review reveals a potential gap between the clinical practice where BVA is utilized and the conditions explicitly addressed in the CPGs. Laboratory experiments have identified the therapeutic effects of BVA for immunological and neurological diseases, including autoimmune diseases and Parkinson's diseases [13]. There is also clinical evidence suggesting that BVA may be beneficial in several areas not covered by these CPGs, such as chemotherapy-induced peripheral neuropathy of cancer patients [42], bone fracture [43], or Parkinson's disease [44]. Furthermore, the CPGs often lacked specific treatment protocols tailored to factors such as age, gender, disease severity, or associated symptoms. Even for conditions included in the CPGs, the treatment protocols, including acupoint selection criteria, dosage, and treatment duration, were frequently unspecified. This absence of detailed guidance may hinder the implementation of BVA in clinical practice, as clinicians may struggle to adapt the recommendations to individual patient needs. Future CPG development should focus on expanding the scope of conditions covered and incorporating more granular treatment protocols to address these gaps. The moderate to low levels of evidence supporting BVA recommendations pose challenges for clinicians seeking to adopt these guidelines. The level-downgrading due to the RoB of the primary studies may stem from methodological limitations such as inadequate randomization, lack of blinding, or incomplete outcome reporting. To address these issues, future research must prioritize globally standardized trial designs adhering to frameworks like Consolidated Standards of Reporting Trials (CONSORT) [45] and Standards for Reporting Interventions in Clinical Trials of Acupuncture (STRICTA) [46]. The imprecision observed in several recommendations for BVA therapy implies the need for confirmatory RCTs with sufficient sample sizes. Most current studies lack statistical power to detect clinically meaningful differences, limiting their utility in guiding practice. Furthermore, the lack of standardization in venom dosage and administration protocols remains a significant barrier to high-quality BVA RCTs. Additionally, concerns regarding patient safety, including potential adverse reactions and anaphylaxis risks, necessitate rigorous safety assessments and standardized monitoring protocols in future trials. The predominance of B or C grades in BVA recommendations can be attributed to the primary studies' methodological limitations.