Prameha and Diseases of Udakavaha Srotas
Prof. Muralidhar Sharma
based on the lecture available at–Prameha and Diseases of Udakavaha Srotas
Another category of the patients that are recently diagnosed as diabetes and opting for Ayurvedic management. These patients want to have only Ayurvedic treatment, and associated with noncompliance and drop outs. I don’t say that those patients could be satisfied. In diagnosed case of diabetes and those are not taking any kind of treatment then I would focusing on certain clinical symptoms like neuritis, vascular pathology, albuminuria and cardiovascular status. It is very commonly observed that diabetic patient usually does not take treatment in regular manner and floating in nature, visiting to multiple doctors.
Screen for allied complications
If the patient has any of complication mentioned above, energetic treatment is required. I don’t say that the patient can be managed with only our treatment and I would not give Virechana. But if the patient has a persistent hyperglycaemia which according to WHO is impaired glucose tolerance in such condition,II would be Chandraprabha Vati, Arogya Vardhini and Avipathikar along with godanti. I would advise Virechan only to those patient who will follow Samsarjan Krama properly.
In case of high risk patients my choice would be
- Asanadi Kwatha,
- Chandraprabha vati
I reserve Asanadi Kwatha to comparatively low risk category where a patient has impaired glucose tolerance.
HBA1c less than7.5 to 8, uncomplicated cases with blood sugar level within 200 mg/dl:
I would advise diet, exercise, and Virechan without specific medications. Many of the patients will be benefited and such type of treatment attitude is for those where there is no evidence of risk. In case of risk identified potential cases, considering it as diabetes I would prescribe
- Asanadi Kwatha,
- Chandraprabha vati
On medical management (Satisfactory glycaemic control) opting for Ayurvedic treatment:
Be cautious while managing patients who has received satisfactory medical management and willing to shift over Ayurvedic management. Patients, who have already taken some medicines or many times taking too many medicines in such cases, my advice would be not to change over medicine all of sudden or abruptly.
Abrupt changes in prescriptions can produce spikes in blood sugar levels and spikes in the blood sugar level are more dangerous than constantly high blood sugar. Constantly high blood sugar is safer than fluctuations or spikes in blood sugar levels. I do prescribe the same medication discussed before like Asanadi Kwatha, Arogyvardhini, Chandraprabha Vati/Diabecon.I usually do not prefer to use patented drugs but Diabecon is one of the the patented drugs which I use in my practice very often. Earlier I used to prescribe Vang Bhasma or Jasada Bhasma, later there was a problem with the market. So I selected Diabecon and occasionally used that in patients who are otherwise resistant. After regularly monitoring blood sugar levels and if once blood sugar level is maintained optimally, then I try to reduce those oral hypoglycemic drugs, otherwise, withdrawal from the existing regimen is a very complex issue.
If all is well advise the patient not to shift over. The changeover is gradual so that there are no spikes.
Withdrawal of the existing regimen is a complex issue, particularly when multiple drugs are prescribed.
My prescription would be
Chandraprabha Vati / Diabecon
The strategy of withdrawal of oral hypoglycaemics
In the present market fixed dose multiple combinations of oral hypoglycaemic are available eg. M1,M2. Also there are many brands and every sort of anti-diabetic drug is mixed in different proportion. That’s not really a classical treatment and many of the patients develop complications because such drugs are prescribed. In my opinion use of multiple drugs would be safer because it will have more potential activity but that doesn’t mean that you have to go on prescribing these fixed dose combinations. Of course many modern doctors agree with me, but it’s about the market issues like the economy of the market.
Considering our point of view, the problem will be when such a patient has to be treated and when to withdraw the medicines, also which of the drug has to be drawn.
So I would always suggest such patients to shift over generic medicines and the patient may also save some money. If a patient comes to me with multiple drug regimens and if the patient seems to continue with our treatment, I will gradually change the patient to the same content with combination to generic medicine. Once the patient is in generic medicines we can withdraw individual drug comparatively easily because now you can have a choice .When you have that multiple combination available in the market, it will be quite difficult and virtually not possible to remember all that ratios of drugs and we have too many of that market products..
Strategy of withdrawal of oral hypoglycaemics
The basic idea which of the drug to be withdrawn and associated conditions I have tried to summarize this. Sulfonylureas and metformin are the primary oldest of the drugs which still remain potent,whereas all the other drugs are later editions and later the edition, newer the drug that we have more risk. But majority of the patients, we have newer prescriptions but that’s the general trend. So I’m not criticizing the other system but this is what is exactly going. New drugs are always with risk so I would always reduce those newer drugs try to maintain patients either on sulfonylureas or metformin along with our ayurvedic drugs. So that’s the idea our drug treatment will be continued and that drug could be tapered gradually ensuring that there is no fluctuation in blood sugar levels. Whenever there is any specific reason, like a patient who is having the symptoms related with gastrointestinal tract, majority of those patients, there could be a possibility that these symptoms could be precipitated due to drugs like sulfonylureas, in that condition will try to avoid the sulfonylureas. If the patient has a hepatic or respiratory complications, I would try to reduce that Meglitinides eg,Repaglinide and nateglinide .If there is a tendency to gain weight, patients who tend to gain weight, it is better to withdraw Metformin if possible. Now, all this would be a possible depending upon the possibility, not an easy job to explain that would be quite difficult. Trying to make it as simple as possible. Don’t think that the whole issue is very simple, it’s very complicated. If the patient has a cardiac symptoms like developing pedal odema then usually it could be due to Thiazolidinediones groups of drugs and in that try to reduce them. If the patient has α-Glucosidase inhibitors then if there is a tendency for hepatic involvement and particularly alkaline phosphates level being raised, try to withdraw that drug. So that’s how I go into that. Of course Cycloset is rarely prescribed in among our patients, won’t be very sophisticated patient, maybe in a few years, everyone will be describing the same. So that’s about one of the issues which is very complex and I don’t think that I would be able to explain exactly the situation as it advanced to simplify. Whenever we have to withdraw drug the general rule is do not result in spikes, there should not be spikes in the level. So we have maintained both together and maintain that uniform stability, glucose level maintenance.
Strategy of withdrawal of oral hypoglycaemics
- Sulfonylureas (glipizide, glyburide, gliclazide, glimepiride)- GIT symptoms
- Meglitinides (Repaglinide and nateglinide) –Hepatic renal and Respiratory symptoms
- Biguanides (Metformin)-Renal involvement,- Weight gain
- Thiazolidinediones (rosiglitazone, pioglitazone)-Cardiac symptoms ,Oedema
- α-Glucosidase inhibitors (acarbose, miglitol, voglibose)-Hepatic involvement
- DPP-4 inhibitors (sitagliptin, saxagliptin, vildagliptin, linagliptin, alogliptin)- GIT involvement
- SGLT2 inhibitors (dapagliflozin and canagliflozin)- Renal involvement
- Cycloset (Bromocriptine)-Neurological symptoms [ Rare prescriptions]
- Unsatisfactory glycaemic control – Opting for Ayurvedic management / Supplement
Another group of patients are having unsatisfactory glycemic control and they are opting for Ayurvedic treatment. There is nothing specific about this category of patient, the only thing is you have to be aware of the complications. These patients are belonging to risky category when they have the complications, there will be a possibility that ayurvedic drugs are blamed. So educating the patient about that is a very important issue. The whole of the target is to prevent or postpone complication than really the management of diabetes. There is absolutely any of ayurvedic drug that can be safely prescribed. There is no risk developed by prescribing our drugs like particularly Asanadi ,Chandraprabha etc . Of course the basic issue of modifying that contemporary drugs is a very delicate issue. The method is the same, dropout rates are usually high because these patients are not such patients who continue to be the treatment. So, I would always say like if possible take evaluation in the beginning, if the patient has taken the medicine for a few months and then drops off then instead if you reject the patient in the beginning, but of course not that every patient is rejected, that depends on one another, delicate perception of the patient. But you have to be careful that they make and the safety part also has to be careful about that.
The target is to prevent /postpone the complications.
Ayurvedic drugs can be safely co-prescribed.
Modification or withdrawal of existing prescriptions is a delicate issue.
Dropout rates are high.
5,6—Stable/unstable glycaemic control – other accompanying disorders
The next category of patients is stable, with well-controlled blood sugar levels and some other accompanying disorders. Such patients say openly that for diabetes they are taking some other consultation and treatment. Among my patients, these patients constitute a major category.
The rule is whenever a patient would have another disorder, either neurological or any of the conditions, the line of management would be the same as we follow in other diabetic patients. The results would be comparatively less predictable and the duration of the treatment required to be longer, in other patients if I say three weeks of treatment for chronic bronchitis, in a diabetic patient it may require six weeks or so on. Otherwise comparatively you do not have much of a problem there, because the headache of maintaining the diabetes is managed by others. Also, there is no risk of advising any of the medications. Another common misperception among Ayurveda physicians is whether to prescribe Asavas or sugar-containing preparations. I do prescribe it whenever there is a need because Asavas are one of the categories of drugs that are mentioned in our texts as a treatment of Prameha and they are indicated. Definitely, you can prescribe them without any hesitation, and also it will not affect glycaemic control. The only thing is the duration of treatment has to be longer.
- No adverse effects of co-prescribing.
- As far as possible no meddling with the existing antidiabetic regime.
- Asavas or sugar-containingining choornas can be prescribed without any disadvantage.
- Duration of treatment and expected target results differ from otherwise healthy patients.
- 7. Diabetic complications – A] Microalbuminuria
Another major category of patients who come to me is where the patients presenting with further complication,among them the, commonest complication is micro albuminuria, a tendency to develop nephropathy or full pledged nephropathy. Fully developed nephropathy I consider it as real Madhumeha, the end stage of any type of Prameha results in final stage called Madhumeha.
If the patient is already on other medication, I’ll try to maintain that. If the patient is on insulin, I try to maintain that insulin. I would prescribe Chandraprabha, Punarnavamandoor, Amrutarishta, with these medications many of the patients can be maintained that the safe level for quite significant duration and virtually you can postpone that complication of the established nephropathy.
Chronic renal failure
The patients having a real nephropathy I will be preferring Asanadi, Chandraprabha, Punarnavamandoor considering this as the Shotha or Madhumeha. The issue is the serum creatinine level, if it is above 6mg, it’s better to have dialysis, virtually our treatment really may not produce a significant change. So I would advise the patient to go for dialysis if creatinine level is more than 6 mg. But below 6 mg we can maintain the patient for quite a long period without going for the dialysis. But other treatments whatever is being given particularly if it is insulin we can maintain. I have seen a patient who is my patient for seven years whose creatinine level is fluctuating between 5-5.6 mg for the past seven years. I can claim that that’s because of our treatment creatinine level is maintained. Otherwise usually the trend will be once the patient reaches that level of 5mg the next deterioration will be faster and usually within one year the patient will have a end stage failure where dialysis will be required. So we can prevent dialysis to a great extent. The only thing is the selection of the patient should be optimal. If you have selected such a patient who has already caused that cut off limit, then our treatment may not be beneficial and a good number of patients come to only at that level. They remember about Ayurveda only when they have come to that state and that again will have a general trend a tendency to take up. So that’s all the issue. So I would be very selective in that in my practice. If the patient has such a very high risk, I would not take up that patient and advise dialysis. All the target is not the cure, you cannot expect the patient to be cured but only maintenance of serum creatinine below 6mg. Seven years postponement for dialysis is quite significant, which is not otherwise possible. So we can definitely tell that our treatment is significant, but at the same time we have to be level headed. We can’t say that with our treatment, we can manage everything and our target should be about maintenance of the patient at that level.