E-ISSN:2456-3110

Case Report

Rheumatoid Arthritis

Journal of Ayurveda and Integrated Medical Sciences

2023 Volume 8 Number 7 July
Publisherwww.maharshicharaka.in

Intervention of Amavata w.s.r. to Rheumatoid Arthritis through Ayurveda: A Single Case Study

Kritika.1*, Rao N.2, Padmakiran C.3
DOI: http://dx.doi.org/10.21760/jaims.8.7.44

1* Kritika, Post Graduate Scholar, Department of PG Studies in Panchakarma, Shri Dharmasthala Manjunatheshwara College of Ayurveda, Udupi, Karnataka, India.

2 Niranjan Rao, Professor and HOD, Department of PG Studies in Panchakarma, Shri Dharmasthala Manjunatheshwara College of Ayurveda, Udupi, Karnataka, India.

3 C Padmakiran, Associate Professor, Department of PG Studies in Panchakarma, Shri Dharmasthala Manjunatheshwara College of Ayurveda, Udupi, Karnataka, India.

Amavata is the systemic disorder in which pathogenic constituents are mainly Aama and Vata. The symptoms of Amavata are identical to Rheumatoid arthritis. It is an auto-immune and most common persistent inflammatory disease occurring throughout the world in all ethnic groups with a male to female ratio of 1:2-3. Amavata, is explained in Laghutrayees and was first time described in Madhav Nidana as a separate clinical entity in the 7th century. In modern medicine treatment has its limitations, whereas in Ayurveda, its effective management is detailed for its different states. Moreover, Panchkarma has potent Shroto-vishodhna effect and is found as a promotive, preventive and curative measure in the patient of rheumatoid arthritis. In this case study a 14 year old diagnosed case of Amavata has been treated with Alepa, Dhanyamla Dhara, Vaitarna Basti as Shodhana and tablet AIMFLAM MR, Chitrakasavam as Samshamana Aushadha for 7 days and after that tablet FLEXOFEN, Vidangarishta, Kanchanar Guggulu as Samshamana Aushadha for 30 days and patient showed remarkable improvement in all the symptoms.

Keywords: Amavata, Rheumatoid Arthritis, Vaitarna Basti, Kanchanar Guggulu, Ayurveda, Case Study

Corresponding Author How to Cite this Article To Browse
Kritika, Post Graduate Scholar, Department of PG Studies in Panchakarma, Shri Dharmasthala Manjunatheshwara College of Ayurveda, Udupi, Karnataka, India.
Email: 		Kritika, Niranjan Rao, C Padmakiran, Intervention of Amavata w.s.r. to Rheumatoid Arthritis through Ayurveda: A Single Case Study. J Ayu Int Med Sci. 2023;8(7):229-234.
Available From
https://jaims.in/jaims/article/view/2255

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2023-05-27 2023-05-29 2023-06-05 2023-06-12 2023-06-19
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
Nil Nil Yes 17%

© 2023by Kritika, Niranjan Rao, C Padmakiranand 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

Rheumatoid Arthritis is an autoimmune disease in which the immune system of the body attacks its own tissues i.e., cartilage and synovial membrane characterized by persistent inflammation of peripheral joints with associated systemic features. It is characterized by inflammation of joints, which causes swelling, pain and loss of function.[1] It is a chronic systemic inflammatory disorder that may affects many tissues and organs including skin, blood vessels, heart, lungs and muscles but principally attacks the joints producing a non-suppurative proliferative synovitis that often progress to destruction of the articular cartilage and ankylosis of the joints. It occurs more commonly in females than males, with a 2-3:1 ratio. Annual incidence of rheumatoid arthritis is approximately 3 cases per 10000 population and prevalence rate of 1% peaking in age group of 35 to 50 years.[2] Clinically Amavata resembles the symptoms of rheumatoid arthritis.[3]

Looking at the Nidana or causative factors of Amavata, indulgence in incompatible foods and habits, lack of physical activity, or doing exercise after taking fatty foods leads to indigestion and produce Ama, associating itself with vitiated Vata, circulated throughout the body and accumulates in Sleshma Sthana, leading to the disease Amavata.[4] From a modern point of view patients with rheumatoid arthritis are at increased risk of developing thyroid dysfunctioning, especially hypothyroidism.[5] Moreover, signs and symptoms of hypothyroidism can be corelated with symptoms of Dhatvagni Mandya.

Here in the Samprapti of Amavata, Ama and Kapha Dosha are mainly involved. Amavata is a Vyadhi having Bahudoshawastha, where Kapha, Vata, Pitta Dosha are predominantly involved. Its Udbhava Sthana is Amapakwashaya, Vyaktasthana is Sandhi. So, the therapeutic approach should be on correction of vitiated Vata Dosha, Kapha Dosha, Amadosha and correction of Agni that shows Pitta involvement.

For management of this, individualized Ayurvedic interventions have demonstrated clinically significant improvement in rheumatoid arthritis as per allopathic treatment with added advantage of lesser side-effects according to a study.[6]

So, in Ayurveda the principles of treatment for Amavata are Langhana, Swedana drugs having Tikta, Katu Rasa and Deepana action Virechana, Snehapana and Anuvasana Basti as well as Kshara Basti.[7] Whereas, Acharya Chakradutta has described line of treatment for the management of Amavata as Langhana (emaciation therapy), Swedana (sudation), Tikta, Deepani, Katuni (drugs having bitter and pungent taste which increases digestive fire), Virechana (therapeutic purgation), Snehapanam (oral administration of medicated ghee and oil), Basti Karma (medicated enema), Saindhavadi Anuvasana Basti.[8]

Case Description

A female patient aged 14 years currently pursuing her studies came to our care on 23.03.2022 with complaints of multiple joint pain since 1 year associated with morning stiffness and swelling of joints. The pain is present bilateral and aggravates in morning, as well as on exposure to cold, in cold season. Earlier morning stiffness persisted for quite less time but now it lasts up to an hour. Patient is a known case of hypothyroidism since last one year and has been taking Tablet Thyroxine 25 mcg early morning once a day. She took allopathic treatment for the same but did not get any satisfactory relief so, now has come for Ayurvedic treatment.

On Examination

General Examination: General Examination findings on first visit are given below.

General examination

Ashta Sthana Pariksha

Nadi - 67/min

Mala - Kathina

Mutra - Prakrut

Jihwa - Lipta

Shabda - Prakrut

Sparsha - Ushna

Druk - Prakrut

Akruti - Sthoola

General Examination

Pallor - present

Icterus - absent


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Clubbing - absent

Lymph nodes - absent

Oedema - present

Appetite - Normal

Bowel - Hard stools associated with abdominal bloating

Micturition - Regular

Sleep - Disturbed

Systemic examination

CNS - HMF intact

CVS - S1 S2 HEARD

RS - NVBS HEARD

Per Abdomen - Soft, Non tender, No Organomegaly

Musculo skeletal examination

Inspection - Difficulty in flexion and extension of knee, ankle, metacarpophalangeal, proximal interphalangeal, thumb interphalangeal, metatarsophalangeal and wrist joint with swelling in both the limbs.

Palpation - Tenderness in knee, ankle, metacarpophalangeal, proximal interphalangeal, thumb interphalangeal, metatarsophalangeal and wrist joint. Raise in temperature of the knee joints and ankle joints.

Table 1: Blood investigation

Blood Parameters Result on 23.03.2022
Haemoglobin 11.5 gm%
ESR 80 mm/ 1 hour
RA Factor 0.1 IU/ml
C reactive protein 26.0 mg/L
ASO titre 43.6 IU/ml
SGOT 81.0 U/L
SGPT 40.0 U/L

Diagnosis

Amavata/ Rheumatoid Arthritis

Diagnostic Criteria of Rheumatoid arthritis

  • Samanya Lakshanas of Amavata: Angamardha, Aruchi, Trushna, Gourava, Sandhi Shotha, Sandhishoola, Shoonatanga, Ajirna, Alasya, Apaka.
  • 1987 ACR Revised criteria.[9]

Table 2: Classification criteria for Rheumatoid Arthritis

Criterion Grading Score
Joint involvement 1 large joint (shoulder, elbow, hip, knee, ankle) 0
  2-10 large joints 1
  1-3 small joints (MCP, PIP, thumb, IP, MTP, wrists) 2
  4-10 small joints 3
  >10 joints (at least 1 small joints) 5
Serology Negative RF and negative ACPA 0
  Low-positive RF or low-positive anti-CCP antibodies ( 2
  High-positive RF or high-positive anti-CCP antibodies (>3 times ULN) 3
Acute-phase reactants Normal CRP and normal ESR 0
  Abnormal CRP and abnormal ESR 1
Duration of symptoms <6 weeks 0
  >/= 6 weeks 1

Patients with a score >/= 6 are considered to have definite RA.

Table 3: Result on Assessment

Variable Before Treatment
Joint involvement 5/5
Serology 0/3
Acute phase reactants 1/1
Duration of symptoms 1/1

Intervention: The patient was admitted in the hospital on 23.03.2022 the following treatment was given to patient listed in table 5.

Table 4: Treatment given

Panchakarma Agni Chikitsa Lepa 7 days
  Dhanyamla Dhara 7 days
  Vaitarna Basti as Kala Basti 7 days
Shamana Aimflam Mr 1 BD
  Chitrakasava 15 ml TDS

Table 4.1: The ingredients of Agni Chikitsa Lepa

Name of the drug Quantity
Dry drugs  
Lashuna 10 buds
Lavanga 10 grams
Maricha 10 grams
Sarshapa 5 grams
Haridra 5 grams
Wet drugs  
Kshudra Agnimantha Leaves of these drugs are used
Vanatulasi Each drug is taken in equal quantity
Nirgundi Quantity sufficient enough to prepare a paste to apply all over body of the patient Quantity varies according to the patient
Papata
Bandha

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Table 4.2: The ingredients of Dhanyamla Dhara

Name of the drug
Dry drugs
Shallaki
Kulattha
Pruthuka
Laja
Kangu bheeja
Kodrava
Tuvaraka
Maasha
Ajwain
Shunti
Wet drugs
Nimbuka
Moolaka

Table 4.3: The ingredients of Vaitarana Basti

Name of drug Quantity
Saindhava Lavana 12 grams
Guda 25 grams
Moorchitha Tila Taila 50 ml
Gomutra 200 ml
Chincha Kalka 50 grams

On discharge she was advised to take following oral medication for 30 days listed in table 6.

Table 5: Medication advised on discharge for 30 days

Medication Dose Anupana
Vidangarishta 15ml Tds Anaushnasheeta Jala
Kanchanar Guggulu 1 TDS Anaushanasheetajala
Tablet Flexofen 1 TDS Anaushnasheeta Jala

Pathya Apathya

The patient was advised to take light, hot and fresh food articles.

She should avoid curd, heavy and oily food and citrus fruits etc.

Result

Table 6:

                                                                                                             Before Treatment After Treatment
Joint involvement 5/5 1/5
Serology 0/3 0/3
Acute phase reactants 1/1 1/1
Duration of symptoms 1/1 1/1

Table 7:

Variable Before Treatment After Treatment
Angmarda + -
Aruchi - -
Trishna + -
Alasya + -
Gaurava + -
Sandhi Shotha + -
Sandhishoola + -

Table 8:

Blood Parameters Before treatment on 23.03.2022 After treatment on 10.05.2022
Haemoglobin 11.5 gm% 11.6 gm%
ESR 80 mm/ 1 hour 52.0 mm/ 1 hour
RA Factor 0.1 IU/ml 0.4 IU/ml
C reactive protein 26.0 mg/L 1.2 mg/L
ASO titer 43.6 IU/ml 86.1 IU/ml
SGOT 81.0 U/L 47.0 U/L
SGPT 40.0 U/L 32.0 U/L

Discussion

Treatment given is of Amapachana, Srotoshodhana and Vata Chikitsa Upkrama. Ayurveda cures the cause of the disease which leads to the violation of Samprapti of the disease. Acharya Chakradatta spoke about the Chiktsa Sutra of Amavata. It includes Panchakarma processes such as Langhana, Sweden, Virechana, Snehapana, Anuvasana Basti, Tiksharabasti and the use of herbal remedies with Tikta, Katu Rasa and Deepana. As the line of treatment of Amavata is Langhana (fasting), Swedana (sudation) having Tikta, Katu Rasa and Deepana action Virechana (therapeutic purgation) Snehapana (oral intake of medicated ghee) and Anuvasana as well as Kshara Basti.[10]

In this case, Alepa and Dhanyamladhara were advised along with Vaitarna Basti. Alepa is prepared out of Ushna Veerya Dravyas like Haridra, Sarshapa, Lashuna, Lavanga, Maricha and Vatahara leaves. This helps in attaining Niramavastha. Dhanyamla Dhara is another procedure employed here which helps in relieving stiffness, pain. It is a type of Drava Sweda which is indicated in Samsrushtavasta of Doshas. In Ashtanga Hrudaya, Dhanyamla Dhara is mentioned as Vatakaphapaham, and also for Vata Pradhana Kapha conditions thus, these two procedures showed its action by giving symptomatic relief along with Vaitarna Basti. As there is no doubt that Basti is considered as Ardha Chikitsa and


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Sampoorna Chikitsa by some Acharya’s. Vaitarna Basti is explained in Vangasena Samhita and Chakradatta and its direct indication is given in Shoola, Anaha and Amavata. The qualities of Vaitarana Basti are considered as Laghu, Ruksha, Ushna, Tikshna. Majority of the drugs have Vata Kapha Shamaka action. Owing to these properties treatment with the Basti has provided significant improvement in sign and symptom of disease. The Tikshna Guna of Basti helps in overcoming the Sroto Dushti resulting from Sanga, thus helps in breaking down the pathogenesis of disease. In Shamana Aushadha, tablet Aimflam-MR, whose main contents are Sallaki and Nirgundi, helps in such a way that, Sallaki has Vata balancing property and also helps to reduce Ama. It reduces swelling as well as stiffness in inflamed joints due to its anti-inflammatory property. Whereas, Nirgundi helps in reducing pain due to Vata balancing property. Chitrakasavam balances Kapha and Pitta and increases digestion. Flexofen-MR is a unique combination of Langali, Shunti, Krishna Jeeraka, Shilajit, Ashwagandha, Rasna, Sallaki, Yogaraja Guggulu etc. which acts as a high-speed analgesic without affecting the gastric mucosa. It relieves the pain and inflammation in Amavata. Vidangarishta is mainly Ushna, Ruksha, Teekshna and Vata-Kapha Dushtinashak. It also helps in enhancing Jatharagni. Kanchanar Guggulu contains properties like Ruksha (dry), Laghu (light), and Ushna Virya (hot potency) and has Deepana (appetizer) and Pachana (digestive) properties.

Conclusion

Ayurvedic medicines improved Jatharagni and led to formation of other Dhatu as well as stop the formation of Ama. Basti is considered as the main line of treatment for diseases of Vata Dosha. In Amavata Tridosha involvement is there with predominance vitiation of Vata and Kapha Dosha along with the formation of Ama due to Mandagni and other causative factors. Thus, the treatment selected tackles with all the concerned issue giving us an effective result clinically.

Reference

1. Davidson's Principle and Practice of medicine 18th edition Rheumatoid Arthritis, pp1078.

2. Harison's Principle of Internal Medicine - 20th edition Rheumatoid Arthritis

3. Siddharth N Shah (ed). API text book of medicine. 7th edition, 2006 Pp-1533, pp1160-1164.

4. Tripathi B, Editor Madhav Nidana of Madhavkar, Reprinted. Varanasi: Chaukhambha Sanskrit Sanshtan, 2006; Ch. 25, Vol.1, Ver. 6, pp571.

5. Liu Y-j, Miao H-b, Lin S and Chen Z (2022) Association between rheumatoid arthritis and thyroid dysfunction: A meta-analysis and systematic review. Front. Endocrinol. 13:1015516. doi: 10.3389/fendo.2022.1015516

6. Furst, Daniel E, Venkatraman, Manorama M, et al. Double blind, Randomized, controlled, Pilot Study Comparing Classic Ayurvedic medicine, Methotrexate and their combination in Rheumatoid Arthritis. Journal of Clinical Rheumatology 2011; 17(4): 185-192.

7. Chakradatta, Indradev Tripathi, Chaukhambha Sanskrit Bhavan,2010 Amavata- 25/1,pp225.

8. Sri Govindadas, Bhaishajya Ratnavali, Hindi commentary by Prof Siddhi Nandan Mishra, Chaukhambha Surbharati Prakashana, Varanasi, Edition 2017, Amavatarogadhikar, 29/1; p-596.

9. Fauci A S, Braaunwald E, Ksaper D L, Hauser S L, Longo D LJameson JL, Loscalzo J, Editors, Harrison's Principles of Internal Medicine, 17"h ed. New York: Mc Graw Hill medical, Vol 2, pp-2089.

10. Chakradatta, Indradev Tripathi, Chaukhambha Sanskrit Bhavan, 2010 Amavata- 25/1,pp225.


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