Introduction

Diabetes
Mellitus is a chronic, heterogeneous and life threatening disease. The prevalence of diabetes in 2014 was 382
million which was estimated to scale up to an alarming 592 million by 2035 by
the International Diabetes Federation (IDF). Nearly 80% of people with diabetes
are in the low and middle income countries 1. Moreover greater than 60% of world diabetes
population will be in Asia. India, Nepal and China have shown an increasing
prevalence of diabetes even among the rural population.2.  The
escalating rate of obesity is a major causative factor for increasing prevalence of Type
2 diabetes (T2DM) 3,4. 

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Metabolic
syndrome is considered as the new epidemic of the twenty-first century.  It is a major and
escalating public-health and clinical challenge worldwide in the wake of
urbanization, surplus energy intake, increasing obesity, and sedentary life
habits 5.  MetS confers a 5-fold
increase in the risk of type 2 diabetes mellitus (T2DM) and 2-fold the risk of
developing cardiovascular disease 6. Further, patients with the MetS are at
2- to 4-fold increased risk of stroke, a 3- to 4-fold increased risk of
myocardial infarction (MI), and 2-fold the risk of dying from such an event
compared with those without the syndrome 7 regardless of a previous history
of cardiovascular events 8.

This
case illustrates the therapeutic potential of Ayurvedic mode of management in a
chronic T2DM patient with Metabolic syndrome where conventional treatment is
unable to sustain the desired effects. It also tries to observe clinical reporting
of any adverse drug interactions between ayurvedic and allopathy sytem of medication.  Further it emphasises the need to understand a
patient based on Ayurvedic fundamental principles in order to decipher the unique
‘samprapti’ (mode of pathogenesis) of
the disease before planning the intervention. 

Case presentation

A
55 yr old Indian male presented in May 2017 at OPD of Ayush Wellness Clinic
with complaints of poor glycaemic control inspite of taking oral hypoglycaemic
medication, hypertriglyceridemia and chronic constipation with fullness of
stomach, gas & abdominal bloating. Patient is diabetic for the past 10 yrs
and constipation history is more than 20 yrs. 
Also presents history of hypertension for the past 21/2 yrs
and hypertriglyceridemia for the past 1 yr. 
No history of any type of addiction was present.  His family history was positive for
T2DM. 

When
first diagnosed in 2007 the patient was put on Glibenclamide 5mg.  With increasing blood sugar levels in July 2014
the medication was changed to Metformin & Sitagliptin combination 500mg/50mg
twice daily.  In January 2015 when
diagnosed with hypertension was put on Ramipril 2.5 mg once daily.  In December 2015 the dose of Metformin &
Sitagliptin combination has been increased to 1gm/50mg twice daily with
addition of Glimepiride 1mg once daily as the FBS was 155mg/dl and PP was 271
mg/dl.  In December 2015 the dose of
Ramipril has been increased to 5mg once daily as the blood pressure was not
getting controlled.  At the time of
consultation in May 2017 the patient was on Metformin & Sitalgliptin
1gm/50mg twice daily and Ramipril 5mg once daily.  In March 2016 hypertriglyceridemia and
borderline hypercholestraemia was detected was advised to control diet and do
regular exercise.  The drug compliance
was good and diet & exercise were irregular.  With the oral hypoglycaemic medications the
abdominal complaints got worsened and so stopped Glimiperide 1mg for the past 6
months. Patient was not on any lipid lowering medication.

Diagnostic evaluation &
Assessment

At
the time of consultation the blood reports showed FBS: 83mg/dl, PP: 218mg/dl, HbA1c:
7.9%, Urea: 19mg/dl, Creatinine: 0.7mg/dl, Total cholesterol: 182mg/dl, Triglycerides:
275mg/dl, VLDL: 55mg/dl, HDL: 46mg/dl, LDL: 81mg/dl.  Patient BP was 130/85mmHg, weight 75 kg,
height 171 cm and waist circumference 102cm. 
BMI was 26 which was overweight and waist circumference shows abdominal
obesity. 

Clinically
patient was complaining of chronic constipation, fullness of stomach, gas and
bloating of abdomen.  Patient is
diagnosed as Type II diabetes with Metabolic syndrome & chronic
constipation and on ayurvedic line as Avaranajanya
madhumeha with Vibanda. (Table 1 : Timeline)   (Table 2: Ayurvedic Parameters)

Treatment & Outcome

At
first appointment on 30.0517 patient presented with poor glycaemic control, hypertriglyceridemia,
constipation, fullness of stomach, gas & bloating.  He was put on the following ayurvedic
medicines: Phalatrikadi Kwath, M
Liv Tablet,                         Lavanabhaskar Churna, Arogyavardini
vati (Table 1 Timeline) and asked to continue oral hypoglycaemic  (metformin & sitagliptin 1gm/50mg BD)
& antihypertensive (ramipril 5mg OD) medication as usual.  Further given dietary and lifestyle advice.
(Table 1 Timeline).

The
second appointment on 14.06.17 included a review of laboratory results and an
updated symptom assessment.  The patient
was feeling much better, totally relieved with the GIT complaints and his
laboratory parameters also showed improvement, better regulation of blood sugar
and total control of hypertriglycerides. Blood pressure was normal but no
reduction in weight was observed.  After
two weeks of medication there was no adverse drug interactions reported. (Table
1 Timeline)

The
third appointment on 20.06.17 included an updated symptom assessment.  Patient was complaining again of constipation
and hence supplemented with Eranda taila.
(Table 1 Timeline)

The
fourth appointment on 20.07.17 included a review of laboratory results and an updated
symptom assessment.  Laboratory
parameters showed marked improvement and sustained the improvement noted of
earlier reading of third appointment. 
Patient was better with constipation and gas trouble.  Blood pressure was normal, no reduction in
weight was observed and 2 cm reduction in waist circumference was noted.  Patient was advised to stop M. Liv tablet and
Arogyavardini vati and continue the
remaining medications. Again no adverse drug interactions reported and the
Liver function tests and Kidney functions tests were within normal limits. (Table
1 Timeline)

Discussion

Through its contribution to
cardiovascular disease, stroke and mortality, the increasing prevalence of T2DM
along with Metabolic syndrome is a huge health challenge and an economic burden
to the world.

Ayurveda, the eternal system
of medicine, has documented various clinical conditions and their management
based on its fundamental principles. 
Diabetes mellitus and Metabolic syndrome can be understood and managed based
on the principles of ‘Prameha’ (~umbrella
term for various metabolic disorders involving pathogenesis of urinary system) especially
‘Sthula pramehi’/’Avaranajanya Madhumeha9.

Acharya
Charaka has mentioned that a physician need to examine the three important
factors viz., Samuthana vishesha (the
specific causative factors for disease manifestation) Adhistana visesha (the site of manifestation of disease) and Vikara prakriti (the nature of disease
pathway) for successful management of the patient10. 

As per ayurveda each and
every individual is unique and so his development of illness will also be
unique as well as specific to the individual. 
Hence it is important to decipher the Visesha samprapti (specific mode of pathogenesis) in a patient
based on ayurvedic principles before administering the intervention.

In the present case for the
past 20 years, the patient is constantly suffering with gastric complaints
especially constipation.  Due to
sedentary lifestyle and unhealthy food habits with a family history of diabetes
developed T2DM 10 years back which eventually resulted in Metabolic syndrome.  Due to the chronic vitiation of Apana vata the agni dusti has occurred which further due to kapha, pitta, medo &
raktha dusti kara ahara (diet) and vihara (regimen) resulted in the
manifestation of Avaranajanya madhumeha/Sthula pramehi (T2DM).  This disease condition progressed with time
to manifest into a much severe pathology that resulted in Metabolic
syndrome. 

Important principles of samprapti vighatana are as follows :

·        
Need to regulate and bring anuloma
gati (~normal movement) to Apana vata
by removing the vibandha. 

·        
Remove the aama (~metabolic
toxins) & improve the agni – jataragni, bhutagni & dhatwagni (rasa, raktha & medo)

·        
Avaranajanya madhumeha/Sthula pramehi treatment to be adopted. 

·        
For sthula pramehi though Sodhana (~bio-purificatory therapy) is
advised here considering the chronicity of disease progression, avarana mode of pathogenesis and severe apana vata vitiation, Shamana (~pacifying therapy) treatment
with mrudu (mild) sodhana is found to be more applicable.

So the following treatment
principles are applied before selecting the medications: (Table 3: Rationality of therapeutics)

Along with the above
medication diet and lifestyle modification followed by the patient were also to
be considered for the encouraging results. 
No significant reduction in weight was observed but the patient was
feeling more active and healthy.

Because of lack of proper
documentation there is a serious doubt regarding the allopathy and ayurvedic
drug interactions.  This case documents
that there are no adverse drug interactions.

Limitations

Chronic
conditions and their treatments are usually multifactorial, complicating the
evaluation of cause-and effect relationship between symptoms and treatment. The results cannot be
generalised as the present case stresses the need for individualised approach.

Conclusion

Chronic T2DM with Metabolic
syndrome is at risk of CVD and Stroke and better management will reduce the
risks.  This case demonstrates the need
to stick to the classical therapeutic principles of ayurveda and apply them
rationally to get the best possible outcomes and also throws light on the model
of integrated approach.  The
integrated effect of the therapeutics as well as the patient’s choices and
involvement contributed to the present outcome. 

Patient perspective

‘I feel totally relieved
with the GIT complaints which I was suffering since many years.  With better regulation of blood sugar I feel
more active, energetic and overall quality of life got much improved.’

Informed consent

An informed written consent was obtained from the
patient for reporting this case.

Acknowledgements

This case report was prepared according
to the CARE guidelines11.

 

References:

International Diabetes Federation (2013) IDF Diabetes Atlas.(6thedn). The global burden. 29-31.

Ramachandran A,Snehalatha C, Shetty AS, Nanditha A (2012) Trends in prevalence of diabetes in Asian countries.
World J Diabetes 3: 110-117.

Ramachandran A,Chamukuttan S, Shetty SA,
Arun N, Susairaj P (2012) Obesity in Asia–is it different from rest of the
world. Diabetes Metab Res Rev 28 Suppl 2: 47-51.

Regional Office for the Western Pacific of the World Health
Organization, International Association for the Study of Obesity and the
International Obesity Task Force (2000) The Asia-Pacific perspective: Redefining obesity and
its treatment.

5.   
Jaspinder Kaur A
Comprehensive Review on Metabolic Syndrome Article · March 2014 DOI:
10.1155/2014/943162 · Source: PubMed

6.   
K. G. M. M. Alberti, R. H.
Eckel, S. M. Grundy et al., “Harmonizing the metabolic syndrome: a joint
interim statement of the international diabetes federation task force on
epidemiology and prevention; National heart, lung, and blood institute;
American heart association; World heart federation; International
atherosclerosis society; And international association for the study of
obesity,” Circulation, vol. 120, no. 16, pp. 1640–1645, 2009.

7.   
K. G. M. M. Alberti and P.
Zimmet, “The metabolic syndrome— a new worldwide definition,” The Lancet, vol.
366, no. 9491, pp. 1059–1062, 2005.

8.   
J. K. Olijhoek, Y. Van Der
Graaf, J.-D. Banga, A. Algra, T. J. Rabelink, and F. L. J. Visseren, “The
Metabolic Syndrome is associated with advanced vascular damage in patients with
coronary heart disease, stroke, peripheral arterial disease or abdominal aortic
aneurysm,” European Heart Journal, vol. 25, no. 4, pp. 342–348, 2004.

9.   
Acharya Y.T., editor.
Commentary Ayurveda Dipika of Chakrapanidatta on Charaka Samhita of Agnivesha,
Sutra Sthana; Kiyantah siraseeya adhyaya: chapter 17, verse 78-82. Chaukhamba Sanskrit Samsthana; Varanasi:
2001. p. 103. 

10.
Acharya Y.T., editor.
Commentary Ayurveda Dipika of Chakrapanidatta on Charaka Samhita of Agnivesha,
Sutra Sthana; Trishotheeya adhyaya: chapter 18, verse 44-47. Chaukhamba Sanskrit Samsthana; Varanasi:
2001. p. 108.

11.
Gagnier J, Kienle G, Altman
DG, et al. The CARE Guidelines: Consensus-based clinical case reporting
guideline development. J Clin Epidem. 67(1):46-51.

 

 

 

Table
1 : Timeline

 

Date

Presenting complaints

30.05.17

Poor
glycaemic control, hypertriglyceridemia, constipation, fullness of stomach,
gas & bloating

Date

Past Medical History and Interventions

More
than 20 yrs

Complaints
of constipation, fullness of stomach, gas, bloating

2007

Detected
with T2DM started Glibenclamide 5mg BD

July
2014

Changed
to Metformin & Sitagliptin 500mg/50mg combination BD

January
2015

Detected
with Hypertension started with Ramipril 2.5mg OD

December
2015

Increased
dose of Metformin & Sitagliptin to 1gm/50mg BD plus addition of
Glimiperide 1mg OD

December
2015

Increased
dose of Ramipril to 5mg OD

March
2016

Hypertriglyceridemia
and borderline hypercholestraemia detected

December
2016

Discontinued
taking Glimiperide 1mg OD as it was worsening the abdominal complaints

Details
of Patient visit

30.05.17

14.06.17

18.07.17

Laboratory 
biomarkers & other findings

Fasting
blood sugar

83 mg/dl

102 mg/dl

104 mg/dl

Post
prandial blood sugar

218 mg/dl

150 mg/dl

107 mg/dl

Urea

19 mg/dl

16  
mg/dl

15  
mg/dl

Creatinine

0.7 mg/dl

0.8 
mg/dl

0.8 
mg/dl

Total
cholesterol

182 mg/dl

179 mg/dl

192 mg/dl

Triglycerides

275 mg/dl

97 mg/dl

82 mg/dl

VLDL

55 mg/dl

20 mg/dl

17 mg/dl

HDL

46 mg/dl

49 mg/dl

53 mg/dl

LDL

81 mg/dl

110 mg/dl

122 mg/dl

HbA1c

7.9%

7.2%

Total
Bilirubin

0.5 mg/dl

0.5 mg/dl

Conjugated
Bilirubin

0.1 mg/dl

0.1 mg/dl

SGOT

18 IU/L

17 IU/L

SGPT

38 IU/L

35 IU/L

Blood
pressure

130/85 mmHg

115/75 mmHg

115/80mmHg

Weight

75 Kg

 

75 Kg

Height

171 cm

 

 

Waist
circumference

102 cm

 

100 cm

Diagnosis

Avaranajanya
Madhumeha with Vibanda
– T2DM with MetS and chronic constipation

Therapeutic
Intervention

Duration

Medication

Dose

Frequency

Anupana

30.05.17
to 20.06.17

1.  Phalatrikadi Kwath
 

50ml
 

Twice
a day before food

 
 

2.  M. Liv Tablet
 

2
tablets
 

Twice
a day after food

Warm
water
 

3.  Lavanabhaskar churna
 

5
gm
 

Once
daily before lunch

Warm
water
 

4.  Arogyavardhini vati

2
tablets

Twice
daily after food

Warm
water

20.06.17
to
18.07.17
 

Continuation
of the above medication and

 
 

 
 

 
 

5.  Eranda taila

5ml

Evening
before
Food

Phalatrikadi

Kwath

Lifestyle modification

Advised to take more of green vegetables,
Roti/Chappati, buttermilk, water ( luke warm)
Avoid Curd, Rice, Fried food, excess salt,
Pickles, etc.
Advised to do light exercise like walking
during early morning & evening hours

Outcome

Better
and normal Glycaemic control, normal levels of triglycerides, regular bowel
movements, complete reduction in gas trouble, abdominal bloating &
constipation.
No
adverse drug interactions reported.

 

Table 2: Ayurvedic Parameters

Ayurvedic
parameters

Findings
in the patient

Dosha

Tridosha
with secondary vitiation of Vata (Avarana) (~occlusion)

Dushya

Rasa,
Raktha, Medo (Clinically evident)
Mamsa,
Majja, Sukra,
Ojas (Clinically not evident)

Sthana (site of
pathogenesis)

Vapavaham,
(~omentum) Vasty (~Urinary system) & Pakwasaya (~large intestine)

Agni (~
biological fire)

Jataragni:    Vishamagni
(irregular appetite)
Bhutagni:     Mandagni (decreased
appetite)
Dhatwagni:  Mandagni (Rasa, Raktha, Medo)
 

Srotas
(channels of circulation)

Annavahasrotas
(~channels of digestive system)
Mutravahasrotas
(~channels of urinary system)
Pureeshavahasrotas
(~channels carrying faeces)
Rasavahasrotas
(~channels carrying plasma)
Rakthavahasrotas
(~channels carrying blood)
Medovahasrotas
(~channels carrying adipose tissue)

Avastha (stage
of disease)

Aamavastha
(stage of disease with Aama)

Rogamarga (the
pathway of disease manifestation)

Abhyantara
(Internal pathway) : Vibanda (Constipation)
Madhyama
(~Middle pathway) : Avaranajanya Madhumeha (T2DM)
 

Sadyaaasadyatva
(prognosis)

Krchrasadya
(Difficulty to cure): Avaranajanya Madhumeha
Sadya
(Easy to cure): Vibanda

 

Table
3: Rationality of therapeutics

S.No.

Name of the medicine
administered

Rationality

1

Lavanabhaskara churna

Anulomana of Apana vata and to improve
Jataragni

2

M Liv tablet

Site of action is Yakrut
(liver), adhistana (site) for Bhutagni.  Improving the bhutagni

3

Arogyavardhini vati

Improving the bhutagni
and dhatwagni especially medo dhatu

4

Phalatrikadi kwath

Effective formulation in Prameha, mentioned to be tridoshaja

5

Eranda taila

To cause the Apana
vata anulomana.  It is administered
along with Phalatrikadi kwath as
after 3 weeks patient reported again with constipation.  Initially Phalatrikadi kwath with
Lavanbhaskar churna was able to relieve the vibanda by removing the Kapha
avarana at apana and with the
change of avastha to rookshata,(dryness) eranda taila was supplemented.

 

 

 

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