A comparative study of Vamana and Virechana Karma in the management of Sthula Pramehi w.s.r. to Type-2 diabetes.

In the present study, Vamana and Virechana along with palliative treatment was given to patients of Sthula Prameha (Diabetes mellitus or DM). An attempt was made to compare and evaluate the role of Shodhana therapy (Vamana and Virechana). Total 47 patients of Sthula Pramehi were registered in this study, out of which 38 completed the treatment. The patients were divided into two groups, viz. Vamana with Shamana (Group A) and Virechana with Shamana (Group B). Eighteen patients completed the treatment in Group A and 20 in Group B. Neem giloy satva capsule was used as Shamana drug at a dose of 500 mg twice daily after meals for 30 days in both the groups. The efficacy of therapy was assessed based on relief in cardinal signs and symptoms and blood sugar, lipid profile and other biochemical parameters etc. The results showed that the Vamana provided better relief in signs and symptoms as well as on fasting blood sugar (FBS) and postprandial blood sugar (PPBS) in comparison to Virechana.

RCT Entities:   Population Interventions Outcomes

Introduction

In Ayurveda, Acharya Charaka, has classified Prameha into two types, i.e. Sthula Pramehi and Krisha Pramehi or Santarpanajanya and Apatarpanajanya Pramehi. It can also be correlated with the classification given by Acharya Vagbhata, i.e. Dhatu Kshayajanya and Avaranajanya Prameha, respectively.

The factors which provoke the Vata directly cause Apatarpanajanya Prameha while the factors which provoke Kapha and Pitta cause Santarpanajanya Prameha. In Avaranajanya Prameha, Kapha is the predominant Dosha, while the important Dushyas are Meda and Kleda. In Avaranajanya Samprapti, vitiated Kapha and Pitta obstruct the path of Vata, causing its provocation. Samshodhana is the best treatment for the elimination of Doshas. Vagbhata has mentioned that Doshas should be eliminated through the nearest passage.[1] For the Doshas lying in the upper and lower parts of body, Vamana and Virechana are the appropriate to eliminate vitiated Kapha and Pitta respectively. So, in the present study, Vamana and Virechana have been selected.

Neem giloy satva has been selected for Shamana therapy in both the groups after Samsarjana Krama, as mentioned in Bhaisajya Ratnavali, Prameha Chikitsa Prakarana.[2]

The efficacy of therapy is assessed based on relief in cardinal signs and symptoms and also blood sugar, lipid profile, and other biochemical parameters with Deha Bala, Agni Bala, and Chitta Bala as per Charaka.[3]

Aims and objectives

To assess the effect of Vamana in the management of Sthula Pramehi.

To assess the effect of Virechana in the management of Sthula Pramehi.

To compare the effect of Vamana and Virechana in the management of Sthula Pramehi.

Materials and Methods

Patients with classical signs and symptoms of Sthula Pramehi (Type-2 Diabetes) were selected from the O.P.D. or I.P.D of Department of Panchakarma of I.P.G.T. and R.A., G.A.U., Jamnagar.

A special proforma including all the etiological factors of Prameha with Dushti Laskhanas of Dosha, Dushya, Srotas, etc. was made for assessing all the patients.

The patients were thoroughly questioned and examined on the basis of the proforma, and modern investigations like fasting blood sugar (FBS), postprandial blood sugar (PPBS), lipid profile, etc. were carried out to confirm the diagnosis.

Inclusion criteria

Patients having classical signs and symptoms of the disease according to Ayurveda as well as modern science.

Patients of Prameha having body mass index (BMI) 25-35 kg/m2.

Patients of non-insulin dependent Diabetes mellitus (NIDDM) with blood sugar levels: FBS 126–220 mg/dl or PPBS 180–300 mg/dl.

Patients in the age group of 20–60 years.

Patients otherwise healthy and fit for Vamana and Virechana Karma as per the Ayurvedic classics.

Exclusion criteria

Age <20 years and >60 years.

Patients of Prameha having BMI <25 and >35 kg/m2 and disease chronicity for >10 years.

Patients of Type-1 Diabetes or the patients of Type-2 Diabetes taking insulin.

Patients having complications of Diabetes like nephropathy, retinopathy, diabetic foot, carbuncles, etc.

Patients having Diabetes in association with other endocrinopathies like pheochromocytoma, acromegaly, Cushing's syndrome, hyperthyroidism, etc.

Patients having drug- or chemical-induced Type-2 Diabetes, such as glucocorticoid or thyroid hormone induced, etc.

Patients with genetic syndromes associated with Type-2 Diabetes, such as Down's syndrome, Klinefelter's syndrome, Turner's syndrome, etc.

Patients with complications such as any cardiovascular diseases, renal diseases, carcinoma or any other disease effecting multiple body systems and pregnant women, etc.

Plan of study

Patients having classical signs and symptoms of Sthula Pramehi and known cases of Type-2 Diabetes were selected for the study after confirming the same by investigations. All the patients were randomly divided into two groups:

Group A: Vamana Karma followed by Shamana

Vamana followed by Samsarjana Karma and administration of Neem giloy satva capsule 500 mg/each capsule, was given to the patients, 1 capsule twice daily for 30 days.

Group B: Virechana karma followed by Shamana

Virechana followed by Samsarjana Karma and administration of Neem giloy satva capsule, keeping the same dose.

Criteria for assessment

Assessment was done on improvement in signs and symptoms with the help of suitable scoring method.

Criteria for the assessment of overall effect of the therapies

Total effect of the therapy was assessed considering the overall improvement in signs and symptoms. For this purpose, the following categories were maintained.

Complete remission: 100% relief in the signs and symptoms.

Marked relief: ≥75% relief in the signs and symptoms.

Moderate relief: ≥50-74% in the signs and symptoms.

Mild relief: 26-50% relief in the signs and symptoms.

No relief: <25% relief in the signs and symptoms were considered as unchanged.

Scoring pattern was adopted for signs and symptoms.[4]

Statistical analysis

Paired “t” test was used for statistical analysis in Vamana as well as Virechana groups. For comparison between the both groups, unpaired “t” test was used.

Observations and Results

46% patients were in the age group of 51–60 years, 52% were females and 100% were married. 85% patients of this series were vegetarians and 97% were addicted to tea or coffee. 53% confirmed the family history of Prameha and maximum chronicity was 1–3 years (53%). 38% were having Kapha-Pittaja Sharirika and 53% were having Tamah Pradhan Manasika Prakriti. All the patients had BMI between 25 and 35, and 41% were having Madhyama Jarana Shakti and 40% patients were having Krura Koshtha. Among the chief complaints of Prameha, maximum number of patients were having Prabhuta Mutrata (95%), Trishna dhikya (93%), Kshudha dhikya (82%), Kara-Pada Suptata (42%), Pindikodveshatan (83%), and Avila Mutrata (76%). Also, among the associated signs and symptoms of Prameha, maximum number of patients were having Maithune Ashakti (82%), followed by Nidra-tandra (63%), Alasya (71%), Swedatipravriti (44%) and Sheeta Priyata (19%). Maximum Matra of Triphala Siddha Tila Taila for Samyak Snehana was found to be 800–1050 ml for 39% patients. 71% patients showed Uttam Shuddhi in group A, while 83% patients showed Maddhyama Shuddhi in group B.

In group A, Prabhuta Mutrata, Aavilmutrata, Kshudhadhikya, Trishnadhikya, Pindikodwestanam, and Nisha Mutrata (nocturia) remained controlled with highly significant results both after Samsarjana and Shamana, while complaints like Daurbalya, Nidra-tandra, and Alasya showed highly significant results after Samsarjana but showed significant results after Shamana. Kara-Pada Tala Daha and Klaibya were significantly controlled after Samsarjana and the control was highly significant after Shamana. Kara-Pada Suptata was significant in both the conditions. Insignificant results were seen in Gala Talu Shosha on both the occasions. FBS both after Samsarjana and after Shamana was highly significant, whereas PPBS showed highly significant difference after Samsarjana but was significant after Shamana.

After Samsarjana, 6% patients showed marked relief, 61% had moderate relief, 23% showed mild relief and 11% had no relief in their chief and associated complaints. Here, 22% patients had controlled FBS while 17% patients had marked difference in PPBS. After Shamana, 50% patients showed marked relief in their complaints while 34% had moderate relief in their complaints. Again, FBS of 11% patients showed moderate difference and PPBS of 16% patients was under control.

In group B, highly significant relief was obtained in Prabhutmutrata, Aavilmutrata, Trishnadhikya, Kara pada tala daha, Nisha Mutrata, Atisweda and Pindikodwestana, while Nidra-Tandra and Alasya showed a highly significant result after Samsarjana but only mild relief was observed after Shamana. Gala talu Shosha was equally significant after Virechana and Shamana. In Klaibya relief was significant after Vamana, whereas it was highly significant after Shamana. FBS showed highly significant result both after Samsarjana and Shamana (P<0.001). PPBS, however, showed significant role both after Samsarjana and Shamana (P<0.02).

After Samsarjana, 30% patients had moderate relief while 60% had mild relief in their chief and associated complaints. After Shamana, 70% had moderate relief while 15% had mild relief. After Samsarjana, FBS of 40% and PPBS of 20% patients was under control, while after Shamana FBS of 30% and PPBS of 20% patients was controlled [Tables 1–3 and Figures 1–3].

Table 1

Comparative effects of both Karma (Vamana and Virechana) on the chief complaints in patients of Sthula Pramehi (by unpaired “t” test)

Table 3

Comparative effects of both Karma (Vamana and Virechana) on blood sugar level in patients of Sthula Pramehi (by unpaired “t” test)

Figure 1

Percentage relief on chief complaint – After completion of treatment

Figure 3

Effect on blood sugar levels – After completion of treatment

% Relief on associated symptoms – After completion of treatment

Discussion

Madhumeha (Diabetes) has turned out to be the biggest “silent killer” in today's world. As per the estimate of WHO in its report, at least 171 million people presently suffer from diabetes and this number is expected to rise to 366 million by the year 2030. In spite of tremendous advancement in the modern system of medicine, i.e. oral hypoglycemic agent and insulin, still an ideal drug which can cure Diabetes is not available. It is mandatory to give Deepana-Pachana drug before Aabhyantara Snehapan because their inherent properties of Amapachana and increasing the quantum of Agni.[5] Amapachana helps to reduce the Picchilta of morbid matter so that they can be easily dislodged; that's why Trikatu Churna has been selected as it has Deepan-Pachana as well as Pramehaghna properties.

47% of registered patients belonged to the age group of 51–60 years. This data favor the view of modern science that Type-2 Diabetes is primarily a disease of middle and old age, but obese population may get it at an earlier age.[6]

53% of patients had a positive family history and also chronicity of 1–3 years, as Prameha is an Aanushangi as well as Beej doshaj Vyadhi. So, it mostly affects middle-aged people; living a sedentary life and a positive family history plays a major role in its development.

During the study it was observed that, Vamana Karma is effective in pacifying symptoms like Prabhuta Mutrata and Avila Mutrata. Because both symptoms are mainly due to Kapha Prakopa and Abadha Meda, and for this Vamana is the choice of treatment.

In symptoms such as Kara Pada Tala Daha, Atisweda and Nidra-Tandra, Virechana showed good relief though the result was insignificant. It is because Kara Pada Tala Daha and Atisweda are Pitta predominant features and Virechana is best for Pitta. Nidra-Tandra is a Kapha predominant symptom, but in Prameha, Sthan-Sanshraya of Kapha is in Basti Pradesha. So, this symptom is also relieved by Virechana.

It seems that Vamana by reducing Kapha and Meda helps to minimizing insulin resistance, while Virechana by lowering the hepatic glucose production helps to control blood sugar.

Conclusion

Vamana works well on Kapha dominant Lakshana like Prabhuta Mutrata, and Aavil Mutrata, while Virechana subsides Pitta dominant Lakshana like Kara Pada Tala Daha and Atisweda. Symptoms like Kara-pada Suptata, Kshudadhikya, Trishnaadhikya, Gala Talu Shosha and Pindikodwestana are significantly controlled by both Vamana and Virechana.

Though both the procedures relieve the symptoms, it is Vamana that provides more relief than Virechana. Vamana reduces the levels of FBS, PPBS in comparison to Virechana.

Table 2

Comparative effects of both Karma (Vamana and Virechana) on the associated symptoms in patients of Sthula Pramehi (by unpaired “t” test)