# Bee Venom Acupuncture in Traditional Korean Medicine: A Review of Clinical Practice Guidelines
## 5 Grade of Recommendation for BVA Therapy in TKM-CPGs
Only one recommendation for temporomandibular joint disorder reached Grade A [33], suggesting BVA as a first-line treatment in most patients. A few CPGs did not provide a formal grade, instead offering \"Good Practice Points (GPP)\", indicating consensus support by the expert panel [32; 40; 41]. There were no recommendations graded level D.  
The CPGs considered multiple factors when assigning recommendation grades, including potential benefits, harms, level of evidence, availability in clinical practice, medical costs, and patients' preferences, following the standardized manuals [17; 22; 23]. All CPGs assessed the potential benefits and the level of evidence of BVA treatment. Most guidelines reported positive effects, noting significant improvements in pain relief and functional outcomes for conditions. The CPGs, except for gout [41], also mentioned potential harms. The CPGs for knee osteoarthritis [27] and neck pain due to traffic accident injury [35] performed the harm assessment with the selected primary studies. A larger group of CPGs relied on pre-existing safety reports, literature reviews, or professional consensus to assess harm [24; 25; 26; 28; 29; 31; 32; 33; 35; 37; 39]. However, some recommendations for carpal tunnel syndrome [30], stroke [36], and facial nerve palsy [37] did not draw firm conclusions about the harm of BVA due to insufficient data, while those for benign prostatic hyperplasia [40] and tension-type headache [38] mentioned harm without presenting specific reasons. Fourteen CPGs assessed the availability of BVA in clinical practice. Preceding reports for the utilization statistics of BVA were employed in many recommendations [31; 32; 33; 35; 39; 40; 41], while some proposed the wide availability of BVA based on professional consensus [24; 26; 29; 30; 34; 37; 38]. Some recommendations for ankle sprain [29], cervical pain [25], facial nerve palsy [37], knee osteoarthritis [27], and stroke [36] did not assess availability. \begin{table}
\begin{tabular}{c c c c c c} \hline \hline
**CPG for** & **Grade** & **Harm** & **Availability** & **Medical Cost** & **Patients’ Preference** \\ \hline \multirow{3}{*}{Shoulder pain [26]} & \multirow{3}{*}{B} & Assessed with preceding safety & Assessed with professionals’ consensus & \multirow{3}{*}{NA} & \multirow{3}{*}{NA} \\  & & & & & \\ \hline \multirow{3}{*}{Stroke [36]} & \multirow{3}{*}{C} & Assessed but inconclusive due to insufficient data & \multirow{3}{*}{NA} & Assessed but inconclusive due to insufficient data & \multirow{3}{*}{NA} \\ \hline \multirow{3}{*}{Temporomandibular joint disorder [33]} & \multirow{3}{*}{A *} & Assessed with preceding safety & Assessed with use statistics & Assessed with economic evaluation & \multirow{3}{*}{NA} \\  & & reports & & & \\ \hline \multirow{3}{*}{Tension-type headache [38]} & \multirow{3}{*}{C *} & Assessed, but no specific reasons & Assessed with official literature and professionals’ consensus & \multirow{3}{*}{NA} & \multirow{3}{*}{NA} \\  & & & & & \\ \hline \multirow{3}{*}{Traffic accident injury (whizball-associated disorders I, II) [35]} & \multirow{3}{*}{C *} & Assessed with preceding safety & Assessed with professionals’ consensus & \multirow{3}{*}{NA} & \multirow{3}{*}{NA} \\  & & \(\text{C *}\) reports & & & \\ \cline{1-1} disorders I, II) [35] & & & & & \\ \cline{1-1} \cline{3-5}  & & & & & \\ \hline \hline \end{tabular}  
* * BVA therapy is recommended within the scope of pharmacoupuncture therapy. Note. Grades of recommendations are assigned with A when the treatment is strongly endorsed for implementation in almost all clinical practices, B when the treatment is advisable in the majority of clinical situations, C when the therapy has potential benefits in some but not all clinical contexts, and D when the treatment is not recommended in most clinical practices. Abbreviations. BVA, bee venom acupuncture; CPG, clinical practice guideline; GPP, good practice point; NA, not assessed.  
\end{table} 
Table 4: _Cont._The assessment of medical costs was less common and less conclusive.