E-ISSN:2456-3110

Case Report

Amavata

Journal of Ayurveda and Integrated Medical Sciences

2022 Volume 7 Number 8 September
Publisherwww.maharshicharaka.in

Successful management and withdrawal of conventional medicine in Amavata patient (Seropositive Rheumatoid Arthritis) with an Ayurvedic intervention: A Case Report

Shukla A.1*, Wasnik K.2, R.3
DOI:

1* Archana Shukla, Post Graduate Scholar, Department of Kayachikitsa, All India Institute of Ayurveda, New Delhi, India.

2 Kundan Wasnik, Post Graduate Scholar, Department of Kayachikitsa, All India Institute of Ayurveda, New Delhi, India.

3 Rama Kant Yadava, Associate Professor, Department of Kayachikitsa, All India Institute of Ayurveda, New Delhi, India.

Amavata (~Rheumatoid arthritis) is the most common condition among chronic inflammatory joint diseases. It occurs due to impairment of Agni (digestive fire), formation of Ama (bio-toxin) and vitiation of Vata Dosha. The produced Ama is carried by the aggravated Vata which gets deposited in the Shleshmasthana (Asthi - sandhi) and produces “Amavata”. The clinical features of Amavata are identical to Rheumatoid arthritis. In Conventional medicines NSAIDs, DMARDs, JAK inhibitors and corticosteroids plays a major role in the treatment of this condition; but they have serious adverse effects and have limitations for long-term therapy. Conventional drugs only provide temporary control to the pain but the possibility of further damage to joints remains the same because the root cause of the disorder remains unattended. This issue increases the urge to research the new possibilities of drugs that have predictable efficacy and a low toxic profile in this debilitating disorder. Ayurveda focuses on treating the root cause and breakdown of pathogenesis with the help of modalities like Langhana, Swedana, and use of drugs having Tikta, Katu Rasa and Deepana property, Virechana, Snehapana and Vasti. These procedures help in Amapachana, Vatashamana, and Strotoshodhana and have lesser side effects. Present case study was done on the female patient of Amavata in which the successful withdrawal of the DMARDs and NSAIDs were done with the help of Ayurvedic medicine.

Keywords: Amavata, Ama, Rheumatoid Arthritis, NSAIDs, DMARDs, Case Report

Corresponding Author How to Cite this Article To Browse
Archana Shukla, Post Graduate Scholar, Department of Kayachikitsa, All India Institute of Ayurveda, New Delhi, , India.
Email: 		Archana Shukla, Kundan Wasnik, Rama Kant Yadava, Successful management and withdrawal of conventional medicine in Amavata patient (Seropositive Rheumatoid Arthritis) with an Ayurvedic intervention: A Case Report. J Ayu Int Med Sci. 2022;7(8):162-170.
Available From
https://www.jaims.in/jaims/article/view/1935

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2022-07-28 2022-07-30 2022-08-06 2022-08-13 2022-08-20
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
Nil Nil Yes 19%

© 2022by Archana Shukla, Kundan Wasnik, Rama Kant Yadavaand Published by Maharshi Charaka Ayurveda Organization. This is an Open Access article licensed under a Creative Commons Attribution 4.0 International License https://creativecommons.org/licenses/by/4.0/ unported [CC BY 4.0].

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Introduction

With the modernization of society, most of the dietary habits, lifestyles, and environment have been changing due to this several lifestyle disorders start occurring in people. The increased number of cases of Amavata (~Rheumatoid arthritis) is one of the outcomes. It is the most common condition among chronic inflammatory joint diseases. In this joint becomes tender, painful, stiff, and restricted movements are also observed.[1]

Madhavakar (700AD) was the first one who mentioned the Amavata as an independent disease entity.[2] Amavata is Madhyama Roga Marga disease, as it involves Marma (~vital points of body), Asthi (~bones) and Sandhis (~joints). Amavata occurs due to vitiation of Tridosha (~three regulatory functional factors of the body) though Ama (~bio-toxin) and Vata (~biophysical force) are the initiating factors in its Samprapti (~pathogenesis). Here the produced Ama is carried by the aggravated Vata through the Dhamanis (~tubular vessel) and gets deposited in the various joints and produces features like Angamarda (~body ache), Aruchi (~Unwillingness towards meal), Alasya (~weakness), Sandhi Ruk (~joint pain), Sandhi Shotha (~joint swelling) etc.[3] Amavata is sometimes equated with RA (Rheumatoid Arthritis) due to the resemblance of the clinical features. RA is a chronic, progressive, inflammatory systemic disease affecting the synovial joints with extra-articular manifestations.[4] The prevalence of this disease in India is around 0.15 to 0.38% in men and 0.5 to 0.38% in women.[5] Women are getting more affected approximately 3 times more often than men. The onset of the disease is more frequent during the 4th and 5th decade of life with 80% of patients developing the disease between the ages of 35 to 50 years due to this the national economy is getting badly affected. About 10% of the patient will have an affected first-degree relative.[6] It is a very challenging disease for physicians due to its chronicity, incurability, severe morbidity and crippling nature. In Conventional medicines regimen NSAIDs (Non-steroidal anti-inflammatory drugs), DMARDs (Disease modifying anti-rheumatoid drugs), JAK inhibitors and corticosteroids are used. However, they have serious adverse effects and have limitations for long-term therapy.[7]

NSAIDs have adverse effects on GIT gastrointestinal tract and DMARDs cause hepatic, renal and marrow suppression. Corticosteroids cause fluid retention, hypertension, hyperglycemia, obesity, upset stomach, etc.[8] These drugs only temporarily control the pain, but the possibility of further damage to the joint remains the same because the root cause of the disorder remains unattended. This issue increases the urge to research the new possibilities of drugs that have predictable efficacy and a low toxic profile in this debilitating disorder. Langhana (~intermittent fasting), Swedana (~sudation therapy), use of Tikta (~bitter) Katu (~pungent) drugs & Deepana (~appetizer) drugs, Virechana (~purgation) and Anuvasana Basti (~therapeutic unctuous enema) is the line of treatment for the management of Amavata.[9] Ayurveda focused on treating the root cause and breakdown of pathogenesis and also has lesser side effects. In the case discussed below Ayurvedic medication regimen not only improved the quality of life but also able to get rid of the use of steroid medicines and managed the disease condition.

Patient Information: A 46-year-old female patient visited the Musculoskeletal & Rheumatology (Kayachikitsa) O.P.D. on 27/09/2021 having UHID No. 526111 with chief complaints of Shoola (~ pain), Shotha (~ swelling) and Sthambha (~ stiffness) in the morning in multiple joints from past 4 years. She also had complaints of Klama (~Fatigue), Aruchi (~Unwillingness towards meal), Gaurava (~Feeling of heaviness in the body), Mutradaha (~Burning Micturition) and Malasanga (~ Incomplete evacuation of the bowel). The patient had a history of Hypothyroidism for 7 years for which she was taking a 25mcg Thyroxin tablet and her TFT (Thyroid function test) profile was within the normal limit. She also had a history of spontaneous abortion with normal menstrual cycle history. There is no history of T2DM (Type 2 Diabetes Mellitus)/ HTN (Hypertension) / CAD (coronary artery disease)/ T.B (tuberculosis)/ Seizures/ IBD (Irritable Bowel Disease)/ Psoriasis/ Chikungunya Fever but in family history patient’s sister had history of undifferentiated arthritis. The patient was apparently well before 8 years ago but after her second abortion she developed Sharira Balakshaya (~ Generalized weakness) and Shoola (~ pain) in bilateral upper and lower limbs for this she had taken some multivitamins and calcium supplements along with NSAIDs for


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around 3 -5 months and got relief. The symptoms relapsed again after 4 years and she developed complaints of Sandhi Shoola along with Shotha and Sthambha in the morning, she visited the hospital and there she got diagnosed with RA and NSAIDs along with DMARD’s started the treatment. She took this medication for around 4 years but didn’t get much relief, one of her friends suggested Ayurveda. Knowing the minimal side effects of the Ayurvedic medication she wanted to take the Ayurvedic treatment so she came to the OPD for the treatment of the disease.

Table 1: Aaturbala Pramana Pariksha (examination of the strength of the patient).

1. Prakruti (Constitution of the Body) Vata Kaphaja
2. Sara (Quality of Tissue) Madhyama Sara
3. Samhanana (Body Built) Madhyama
4. Pramana (Anthropometric Measurement) Madhyama (Height 154 cm, Weight 51 kg, BMI 21.5 kg/m2 Normal)
5. Satmya (Adaptability) Madhyama
6. Satva (Mental Strength) Madhyama
7. Ahara Shakti (Food Intake and Digestive Capacity) Madhyama
8. Vyayamshakti (Exercise Capacity) Avara
9. Vaya (Age) Yuva
10. Desha (Habitat) Sadharana

Clinical Findings: On examination, the Prakriti of the patient is Vata Kaphaja while Nadi (~pulse) had the predominance of Vata Pitta. The tongue of the patient was coated showing the presence of Ama. The eye movement of the patient was normal and his speech was clear. The patient had moderate built with a BMI of 21.5 kg/m2. The vitals of the patient were normal with pulse rate 70/min and blood pressure 120/80 mmHg and afebrile. There was no pallor, icterus, clubbing, cyanosis and lymphadenopathy. The patient was conscious and well-oriented to time and place. Systemic examination was done and no abnormality was detected. In the musculoskeletal examination of joints inspection, there was bilateral involvement of joints (i.e., symmetrical), and swelling was present at wrist joint, ankle joint and knee joint. Swelling was also present in right hand 3, rd 4th & 5th PIP and left-hand 3rd & 5th MCP (metacarpal) joints. No change in colour was seen. On palpation tenderness was present over bilateral wrist joint, ankle joint, knee joint and also on the right-hand 3rd, 4th & 5th PIP (Proximal Interphalangeal) and left-hand 3rd & 5th

MCP joints. Range of motion of B/L wrist joint and knee joint was restricted. Local rise of temperature was also noted. A detailed Aaturbala Pramana Pariksha (~examination of the strength of the patient) is given in following table.

Timeline

Table 2: Detailed timeline of the events

Date Event and status of complaints in course of treatment
2017 - 2018 Patient went to Nizam’s Institute of Medical Sciences (Hyderabad T.S) for the complaint of multiple joint pain, there she was diagnosed as seropositive RA patient. The doctor prescribes following medicine – 1.        Tablet Folitrex - 7.5mg two tablet OD (once in a week) 2.        Tablet Folvite - 5mg OD (alternate days) 3.        Tablet HCQ - 200mg HS 4.        Tablet Pantop - 40mg OD 5.        Tablet Naproxen - 250mg SOS 6.        Tablet Tryptomer - 10mg HS As patient doesn’t get any relief from this treatment, so doctors change the dose of Tablet Folitrex from 7.5mg (two tablet) once in a week to 10 mg, two tablet once in a week
2018 - 2021 During this time period patient was taking allopathic medicine from the AIIMS, Delhi where initially patient was on dose of 20mg Folitrex tablet once in a week, on seeing symptomatic relief the dose was reduced to 17.5mg once in a week
27/09/2021 As patient doesn’t get any significant relief from the allopathic medicine, so she wants to discontinue this medication and start the ayurvedic treatment, so she visited the Musculoskeletal & Rheumatology (Kayachikitsa) O.P.D.

Diagnosis: As per the standard diagnostic criteria for RA, the EULAR (2010) Score of the patient is 9/10 and the RA factor and Anti-CCP are also positive. Not only this patient also had the cardinal features of RA which are pain, swelling, and morning stiffness in the joints, joint involvement is bilateral and in extra-articular feature, fatigue was present. According to Ayurveda the Pratyatma lakshanas of Amavata such as Sandhi Shoola (~ Pain), Sandhi Shotha (~ Swelling) and Sthambha (~ Stiffness) are present not only this some features of Samanya lakshanas like Aruchi (~ Unwillingness towards meal), Gaurav (~ Feeling of heaviness in the body) and Shoontanganama (~ Swelling) was also present.

Therapeutic Intervention: As the patient is not willing to get admitted to the IPD ward for the Shodhana Chikitsa (~ Purification Therapy) hence, decided to give Shamana Chikitsa (~palliative treatment) on the OPD basis. The medicine prescribed are given in the following table. Along with the oral medicine Baluka Swedana is also advised to the patient for first seven days.



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Table 3: Medicine prescribed

27/09/2021 1. Chitrakdi Vati 250 mg TID before meal Luke warm water
2. Amritarishta 20ml BID after meal Equal amount of luke warm water
3. Vaishwanar Churna 3gm BID after meal Luke warm water
11/10/2021 1. Simhnaad Guggulu 500mg BID before meal With Dashmoola Kwath
2. Dashmoola Kwath 10gm/30ml BID before meal  
3. Ajmodadi Churna 5gm BID after meal Luke warm water
4. Ashwagandharishta 20ml BID after meal Equal amount of luke warm water
5. Panchaguna Taila L/A SOS  
25/10/2021 1. Simhnaad guggulu 500mg BID before meal With Dashmoola Kwath
2. Dashmoola kwath 10gm/30ml BID before meal  
3. Ajmodadi Churna 5gm BID after meal Luke warm water
4. Chandraprabha Vati 250 mg BID after meal Luke warm water
5. Ashwagandharishta 20ml BID after meal Equal amount of luke warm water
6. Panchaguna Taila L/A SOS  
8/11/2021 1. Simhnaad guggulu 500mg BID before meal With Dashmoola Kwath
2. Dashmoola kwath 10gm/30ml BID before meal  
3. Ajmodadi Churna 5gm BID after meal Luke warm water
4. Chandraprabha Vati 250 mg BID after meal Luke warm water
5. Ashwagandharishta 20ml BID after meal Equal amount of luke warm water
6. Panchaguna Taila L/A SOS  
10/12/2021 1. Simhnaad guggulu 500mg BID before meal Luke warm water
2. Dashmoola kwath 10gm/30ml BID before meal  
3. Ajmodadi Churna 5gm BID after meal Luke warm water
4. Shirahshooladi Vajra Rasa 250 mg BID after meal Luke warm water
5. Ashwagandharishta 10ml BID after meal Equal amount of luke warm water
6. Panchaguna Taila L/A SOS  
10/01/2022 1. Simhnaad guggulu 500mg BID before meal Rasana-eranadadi Kwath
2. Rasana-eranadadi Kwath 10gm/30ml BID before meal  
3. Ajmodadi Churna 5gm BID after meal Luke warm water
4. Shirahshooladi Vajra Rasa 250 mg SOS Luke warm water
5. Ashwagandharishta 15ml BID after meal Equal amount of luke warm water
6. Panchaguna Taila L/A SOS  
7/02/2022 1. Aswagandha Churna 5gm BID after meal Luke warm water
2. Panchaguna Taila L/A SOS  

Follow-up and outcome

Table 4: Follow-up and outcome measures

Date Follow up and outcome
11/10/2021 §   Ama lakshanas were subside §   Shoola & Shotha were also reduced §   Feeling of heaviness in the was reduced §   Appetite increases The main course of treatment was started and advised to visit opd after 15 days
25/10/21 1.        Reduction in Shoola & Shotha in multiple joints 2.        Sthambha still persists 3.        Mutradaha was irregular on /off 4.        No pain killer and corticosteroid has been taken Advised to continue the same medication with one new addition and asked the patient to visit the OPD after 15 days with investigations.
8/11/2021 The patient got significant relief and RA factor and Anti-CCP becomes negative, advised to continue the medication with few additions and visit after one month or SOS. 1.        Reduction in Shoola in multiple joints of body. 2.        Shotha gets almost resolved from all the joints except the left wrist joint. 3.        Sthambha in morning time still persists but the duration has been shortened. 4.        Patient no longer feel fatigue 5.        Mutradaha was on /off 6.        Malasanga from last 2-3 days 7.        No pain killer and corticosteroid has been taken till now
10/12/2021 1.        Patient feels better from the treatment 2.        Quality of life improved 3.        Shoola and Shotha gets almost resolved from all the joints 4.        Sthambha in morning still persists 5.        Pain in cervical region and occipital region of head 6.        Mutradaha is also reduced Advised to continue the same medication along with the withdrawal of some medicines according to the present complaints and asked to visit the OPD after one month.
10/01/2022 1.        Pain in multiple joints increases 2.        Headache still persists 3.        No use of pain killer and steroids from last 3 months This time we slightly change the treatment and advised to visit OPD after one month.
7/02/2022 1.        No other complaints as most of the complaints subsides 2.        Minimum medicine has been provided to the patient

The outcome of the treatment on various objective as well as subjective parameters were given in the table no. 4 and 5.1,5.2 & 5.3 respectively.

Table 5: Effect on Objective Parameters

Blood Investigations 27/09/2021 8/11/2021
Hb 11gm/dl 11.9gm/dl
ESR 50mm/hr 30mm/hr
CRP Negative Negative
RA Factor Quantitative 50 IU/mL 18.60IU/mL
Anti-CCP 20 U/mL ˂0.40 U/mL



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Table 6.1: Effect on Ama Lakshanas

Ama Lakshanas 27/09/2021 11/10/2021
1. Srotorodha (~ Obstruction to the channels cell pores) Present Absent
2. Bala Bhramsa (~ Loss of strength) Present Present
3. Gaurava (~ Feeling of heaviness in the body) Present Absent
4. Anilmudhata (~ Inactivity of Vata) Present Absent
5. Alasya (~ Lassitude) Present Present
6. Apakti (~ Indigestion) Present Absent
7. Nishthiva (~ Expectoration of Sputum) Absent Absent
8. Malasanga (~Accumulation of waste materials in the body) Present Absent
9. Aruchi (~Unwillingness towards meal) Present Absent
10. Klama (~Fatigue) Present Present
Score 9/10 3/10

Table 6.2: Assessment of Amavata Lakshanas

Lakshanas 1st visit 2nd visit 3rd visit 4th visit 5th visit 6th visit 7th visit
Shoola (~Pain) 3 2 1 1 2 1 0
Shotha (~Swelling) 3 2 1 1 0 0 0
Sthambha (~Stiffness) 3 2 2 2 2 1 0
Sparshasahta (~ Tenderness) 3 2 1 0 0 0 0
Jwara (~ Fever) 1 0 0 0 0 0 0
Vrishchika Danshavata Vedana 3 2 2 1 1 0 0
Agnidaurbalya 2 1 1 1 0 0 0
Aruchi (~Unwillingness towards meal) 2 0 0 0 0 0 0
Gaurav (~Feeling of heaviness in the body) 3 2   1 1 0 0 0
Utsaah Hani 3 2 1 1 0 0 0
Mukha-Vairasya (~Altered taste of mouth) 3 0 0 0 0 0 0
Vibandha (~ Constipation) 3 0 1 1 0 0 0
Score 32 15 11 9 5 2 0

Interpretations of scoring

0 = Absent

1 = Mild

2 = Moderate

3 = Severe

Table 6.3: Visual Analogue Scale Score

  1st visit 2nd visit 3rd visit 4th visit 5th visit 6th visit 7th visit
VAS Score (out of 10) 10 8 5 2 8 5 2



Intervention Adherence and Tolerability: The patient was strictly adhered to the advised medications and tolerates the administration of Ayurvedic medications. No adverse reaction was complained by the patient during the course of whole treatment.

Discussion

Amavata is a type of complex of disease, whose pathogenesis starts due to generation of Ama formed due to Mandagni. This produced Ama further causes the vitiation of Tridoshas and results in manifestation of Amavata. In pathogenesis of Rheumatoid Arthritis there is formation of auto-antibodies and we can equate this situation with the formation of Ama. So, the main aim of treatment of Amavata is to reduce Ama by Ama Pachana. In this patient the treatment planned under three stages Deepan Pachana, Shamana Chikitsa and Rasayana Chikitsa.

The patient presented with the symptoms of Shoola, Shotha, Aruchi, Gaurava, Klama, Malasanga which suggested the presence of Amavastha in the body to reduce the Ama and to minimize the side effect of modern medicine Pachana and Deepana planned with the drugs Chitrakadi Vati, Amritarishta and Vaishwanar Churna along with Baluka Swedana for first seven days. Both the drugs Chitrakadi Vati[10] and Vaishwanara Churna[11] having the property of Deepana and Pachana along with this the Anulomana Karma by which it reduces the complaints of Aruchi, Gaurava, Malasanga and patient felt energetic. Amritarista corrects the Rasa metabolism and thus reduced the Ama. It also having the antimicrobial activity and hence able to cure various infectious diseases [12] with this activity it minimized the previous side effect of conventional medication.The use of Lavana (~salt) and Kshara (~alkali) along with Hinga (Ferula northex), Ajamoda (Apium graveolens Linn) and Chavya (Piper retrofractum Vahl) in Chitrakadi Vati. Vaishwanara churna also contains Saindhava, Ajamoda, Yavani (Trachyspermum ammi Linn), Haritaki (Terminalia chebula Retz) with their Ushna (~hot), Tikshna, Sara and Anuloma properties they remove the obstruction in Srotas and helps in proper circulation of tissue as well as improves the digestion. The complaints of pain and swelling also reduced.



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Baluka Swedana was used as part of external treatment. Baluka Swedana is a type of Ruksha Swedana having Ruksha and Ushna properties and is mainly used in Kaphaja Vikaras & Amaja condition. It helps in Shoshana (digestion and drying) of Ama present in Sleshma Sthana (joints) and thus decreases the stiffness & pain of the joint it also acts as Shothahara (~anti-inflammatory) and heaviness in the body.[13]

After that main course Shamana Chikitsa were started which Vyadhi Pratyanika medications which includes Simhnaad Guggulu[14] along with Dashmoola Kwath[15], Ajmodadi Churna.[16] Along with this for generalized weakness and vitiated Vata management Ashwagandharishta added and Panchaguna Taila along with Baluka Swedana advised.

Simhnaad Guggulu having Vedanastapana (~analgesic), Deepana-Pachana, Rasayana (~rejuvenation) and Medhya (~intellect enhancer) Karma hence, it has Vatakaphashamaka, Amapachaka, Srotoshodhaka properties which helps in breaking the pathogenesis of Amavata. It is having Agnivriddhikara (~improves digestive fire) with Tikta and Katu Rasa it possesses the antagonistic properties to that of Ama and Kapha and digest Ama Rasa as well as inhibits the excessive production of Kapha. Because of Ushna Virya, it does not allow the Ama to linger at the site of pathogenesis and to create Srotorodha. It reduces Srotorodha and pain. By virtue of Shoshana and Pachana property of Katu, Tikta Rasa, and Ushna Virya, it absorbs excessive Dravta which leads to Samyaka Yuktamagni. Due to Ushna Virya and Katu Vipaka of Simhanad Guggulu, Vatashamana occurs. After Samyaka Yuktamagni and Vatasamana Amavata, Vyadhi Shamana occurs.[17] It possesses anti-arthritic activities due to prevention of breakdown of connective tissue, decreased capillary permeability and improvement of immune system.[18] also, it acts as Rasayana and improves immunity. It also possesses the property of Rasayana and thus rejuvenate the damaged tissues and provides effect for the longer duration of time.[5]

Dashamoola Kwatha having the property of Vatahara and Shothahara and it mentioned in the Amavatarogadhikara and according to the patient condition this chosen for the pain management.

Ajamodadi Churna having Vedanahara property and mentioned in various conditions such as RA, sciatica, joint pains. It possesses the property of Kapha Vatashamaka and thus minimize the obstructive conditions and with anti-inflammatory[19] actions it reduced the condition of RA. And also having Anulomaka property which subsides the condition of Vibandha during the whole treatment.

Along with all this treatment to avoid the extra vitiation of local Vata Dosha Panchaguna Taila for local application had advised for its instant pain-relieving activity with Ushna and Snigdha Guna. Sometimes some other medicines were also added and subtracted according to the patient conditions which includes Chandraprabha Vati[20] for the burning micturition, Shirahshooladi Vajra Rasa for the headache.

After ensuring a marked reduction in pain, swelling and stiffness along with the noteworthy improvement in the quality of life and increased status of Agni, Aswagandha Churna[21] was added for rejuvenation and immunomodulatory action.

Patient complaints subsided within 4 months of treatment and the quality of life of the patient was also improved. During the whole treatment course, the patient did not take any conventional medication.

Conclusion

For the management of Amavata according to the disease stage by assessing the status of Ama, Dosha, Dushya, Agni and Srotasa, before directly going for the Vyadhi Pratyanika treatment need to minimize the Ama by Deepana, Pachana and Srotoshodhana for the proper tissue metabolism and then Vyadhi Pryatyanika for the Shamana purpose and then ensuring the disease condition Rasayana Chikitsa helps to counter the autoimmune diseases like RA and improves the quality of life and with proper Ayurvedic regimen chances to take conventional medication minimizes.

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