Prameha and Diseases of Udakavaha Srotas
Prof. Muralidhar Sharma
based on the lecture available at–Prameha and Diseases of Udakavaha Srotas
Other common diabetic complications
In this condition my additional treatment for the diabetes would be Ekangaveera, Ashvagandharishta or Rajayapna Basti. Rajayapan Basti one of regimen which we prefer in this condition.
Kaishora Guggulu, Manjishthadi kwath or Manjishthadi ksharbasti are advisable.
My treatment would be Arogyavardhini, Manjishsthadi kwath considering it as Uttana Vatarakta
There is no question of a complete treatment and coagulation treatment would be definitely much more beneficial. But along with that we can advise Triphala Choorna with honey and Ghrita. But if patient can afford then it is better to advice coagulation therapy.
Microvascular complications –These are very specifically mentioned in textbooks
रसायनीनां च दौर्बल्यान्नोर्ध्वमुत्तिष्ठन्ति प्रमेहिणां दोषाः, ततो मधुमेहिनामधःकाये पिडकाः प्रादुर्भवन्ति ||Su .chi 12/08
त्रयस्तु खलु दोषाः प्रकुपिताः प्रमेहानभिनिर्वर्तयिष्यन्त इमानि पूर्वरूपाणि दर्शयन्ति; तद्यथा- जटिलीभावं केशेषु, माधुर्यमास्यस्य, करपादयोः सुप्ततादाहौ, मुखतालुकण्ठशोषं, पिपासाम्, आलस्यं, मलं काये, कायच्छिद्रेषूपदेहं, परिदाहं सुप्ततां चाङ्गेषु, षट्पदपिपीलिकाभिश्च शरीरमूत्राभिसरणं, मूत्रे च मूत्रदोषान्, विस्रं शरीरगन्धं, निद्रां, तन्द्रां च सर्वकालमिति||Ch.Ni 4/47
उपद्रवास्तु खलु प्रमेहिणां तृष्णातीसारज्वरदाहदौर्बल्यारोचकाविपाकाः पूतिमांसपिडकालजीविद्रध्यादयश्च तत्प्रसङ्गाद्भवन्ति|| Ch.Ni 4/48
तत्र साध्यान् प्रमेहान् संशोधनोपशमनैर्यथार्हमुपपादयंश्चिकित्सेदिति|| Ch.Ni 4/49
Apart from development of Pidaka all the other complications are also mentioned in texts. symptoms numbness and burning sensation at palm and soles suggestive of peripheral neuritis , physical deformities in the form of symptoms like dryness in mouth and palate, all the different varieties of neuritis are described, reduced vitality are also described. Trishna, Atisar, Jwara, Daha , Daurbalya are the features developed due to toxaemia due to nephropathy. These complications described by Charak and Susuruta suggestive of poor prognosis of disease and without supportive treatment disease may become incurable. So it’s a sort of prescription which is more dependable than only the Ayurvedic prescription in such conditions.
Patients suffering from Gangrene and Ulcers
Majority of patients who are advised the amputation they tend to come to our hospital and a large number of limbs can be saved .My approach is very much conservative in the debridement, it is not a total amputation which is prescribed, regular debridement and the treatment would be Triphala kwatha Parisheka, Jatyadi taila, Manjishtadi kshara Basti.
The treatment has to be very prolonged with consistent effort. So it’s not that you get that results in one week or two weeks, when you have tried this for a long duration. Thus the focused effort would save the limbs.With all that humility, I say I have a credit of saving many limbs.
Triphala kwatha Parisheka, Jatyadi taila
Manjishtadi kshara Basti.
The only thing is it’s not something that can manage at OPD the level, you need to have a hospital infrastructure to take care of the patient and daily monitor. So, to fix your line of treatment as general would be difficult. You need to have regularly modified approved treatment, many times antibiotic have to be co prescribed. Patients who develop other complications, very often due to toxaemia, electrolyte imbalance. So managing those complications as they develop is another important issue. It is not a very simple but it’s possible to manage with our treatment along with the other coexisting treatment. I don’t say that conditions can be treated only with our treatment. All our approaches of Shasthi Upkrama may be useful in a specific condition. So I’m not going to much of the details but it’s possible.
The other complication that is not new, mentioned in the text and it’s considered Asadhya.
या वातमेहान् प्रति पूर्वमुक्ता वातोल्बणानां विहिता क्रिया सा|
वायुर्हि मेहेष्वतिकर्शितानां कुप्यत्यसाध्यान् प्रति नास्ति चिन्ता||Ch. Chi 6/52
When it has resulted in producing Moha due to increased Vata,that shows exactly similar condition to that of ketoacidosis. Virtually the patient has gone into established ketoacidosis. It may not be possible to maintain it with only our drugs, you need to follow the guidelines and correction off fluid loss, correction of the hyperglycaemia with insulin is absolutely necessary. Correction of the electrolyte imbalances, particularly potassium loss has to be managed and correction of the acid base balance, once it is done, ketoacidosis prevention would be possible. So in a patient who comes in ketoacidosis, the primary approaches to bring out the patient from the crisis following these lines and only after that I’ll be prescribing against him Asanadi, Chandraprabha and Arogyvardhini.
- Correction of fluid loss with intravenous fluids
- Correction of hyperglycaemia with insulin
- Correction of electrolyte disturbances, particularly potassium loss
- Correction of acid-base balance
10. Insulin dependent diabetes -Opting Ayurvedic management
Considering all these in Sthool Prameha category while in Krisha Prameha category my prescription would be to continue with insulin. In case of insulin dependent or type 1 category we cannot withdraw insulin completely. But definitely we can reduce the doses, we can very rarely but it may not be possible to completely withdraw the insulin. But with other treatments with Asanadi, Chandraprabha etc we can prevent the complications or postpone the complications effectively.
That’s all about the general in nutshell about my approach to the treatment of diabetes patients and the practical problems they see there.
- Combining ayurvedic regimen can help in prevention of complications
- Help in reducing the dose of insulin.
- Occasionally help in shifting to oral hypoglycaemics.
But it’s not only the medical management, the most important part of the management would be about the diet and exercise. The global data mentioned is that the role of diet and exercises to reduce the HbA1C around 0.5 TO 2%.So simple diet and exercise advises that borderline diabetic patient where HBbA1 is less than 7.5 or 8. Whereas the other role of the spectrum of the drugs, this is not from Ayurvedic point of view, it is data from research articles Sulfonylureas they may help in reduction by 1 to 2%while insulin has maximum capacity. So if the patient has presented a very high level of HbA1C like 10 or more than 10, you need to start with insulin. You cannot maintain the patient only on the diet and exercise. But insulin has to be started at that moment though we consider them as insulin dependent status and it is not an insulin dependent diabetes. This type of classification of insulin dependent diabetes is from older texts. Now a days insulin dependent status and insulin dependent diabetes are two separate conditions. A very highHbA1C is insulin dependent status where you need to provide insulin and then only when the patient’s HbA1c level has come to that level, we may advise the patient to withdraw insulin and a drug can be advice for further maintenance.
Nathan DM. Rosiglitazone and cardiotoxicity: weighing the evidence. N Engl J Med 2007;357. DOI: 10.1056/NEJMe078117
This can be a rough guideline once the patient’s HbA1C is reduced to 7.5 or less than 7.5, we can withdraw other drug and maintain either with diet and exercise or with our Ayurvedic drugs. If HbA1 continues to be more than7.5 then it may not possible to maintain it alone with diet and exercise or Ayurvedic drugs, we need other supportive drugs are needed to maintain the condition.
Every diabetologist has a dietician to provide dietary advice to a diabetic patient. In my opinion, advising diet for diabetic patients is a very unfortunate job. The problem is when they give dietary advice and when a patient received a diabetic diet chart that may have one or two Idali and so on. Here the size of Idali and the calorific value ratio would never be standard. So most of the dietary advice is not really useful practically, it could not reach or adjust to the patient’s lifestyle.
Of course from our scientific point of view, there are many technical terms that are used glycemic index, glycaemic load, calorie value.,diabeto genecity, nutrition value and so on.
- Glycaemic index
- Glycaemic load
- Calorie value
- Nutrition value
Certain idea is necessary regarding these terms because these days Google patients would be always asking such questions and you should have some idea. So I try to as brief as possible.
Calorie is the energy produced by a food and something like the heat generated when you burn a substance. So when you burn a paper it produces the heat, but the heat produced is comparatively lesser but when you burn a wood piece naturally the heat generated is more and for shorter duration. So that’s exactly what we say as diabetogenecity and glycemic index. Glycemic index is the substance which gets absorbed and raises the glucose in shorter duration. It’s not about the quantity .Glycemic load is total quantity of the glucose which is present that’s about exclusively for the carbohydrate contents. Then the calorie value is about the total burn, substances like total energy. Very often the same issue where the patient would say that I would be taking Ghee and avoiding sugar.But one spoon of Ghee is equal to 8 teaspoon of sugar. So when you take one spoon of ghee it as good as taking calorire value of 8 spoon of sugar. taking that’s the calorie value would be almost the calorie value of a teaspoon of sugar. So this is the point which is how to consider and to educate would be quite difficult.The nutrition value is having the other value as such.so that’s in brief issue. And then if you go into the diet prescriptions will have all that low carbohydrate, high protein diet and so on. Again, lots of confusing issues. I try to cut short that we’ll just skip to the next part.
The frequent questions asked by diabetic patients, will be always having many of these questions and one of the important question will be fasting and diabetes, whether it’s beneficial?
- Nil orally for a day at regular intervals – Ekadashi upavasa
- Water fasting: Involves drinking only water for a set amount of time.
- Juice fasting: Entails only drinking vegetable or fruit juice for a certain period.
- Intermittent fasting: Intake is partially or completely restricted for a few hours up to a few days at a time and a normal diet is resumed on other days.
- Ramzan fasting – Nil orally during daytime for 1 month
- Partial fasting: Certain foods or drinks such as processed foods, animal products or caffeine are eliminated from the diet for a set period.
- Calorie restriction: Calories are restricted for a few days every week.
We have different sorts of cultural fasting like Ekadashi fasting, Tuesday or Thursday fasting or Ramjan and so on. So that different patterns of the fasting which are part of our culture exists. Naturally the whole theme of that is to benefit the patient. Removal oft he toxic substances reduce the possibility for diabetes. But the problem would be when we do the ekadashi fasting it is the combination of dashami and dwadashi merging together and that increases the calorie value. Dashami is for preapartion of food on day of fasting and dwadashi is for post fasting food preparation. Thus it increase total inake of calorie.Of course it has definitely a preventive value if followed correctly. But I would advise are onlyUpvasa for those persons who are not on medical treatment for diabetes. If the patient is on medical treatment for dibetes, particularly anti diabetic drugs or insulin that fasting would be more harmful. instead you have to provide a uniform regular level of the food. That would be always beneficial than having these interruptions in food. Interruptions in the food would be definitely beneficial in a healthy person otherwise. And that too instead fasting that is better to have a regular , uniform discipline of food. But all the other form of fasting can also be beneficial if you do not need any regulation.
These days very popular culture is in week you can eat anything , two days you have food regulation and that is more dangerous.It has become very popular among those software people like google people. , for five they use to eat everything and for rest two days they used to take alcohol .Whenever a patient asks about this pattern I say absolutely not, any other issues,like Tuesdays or Thursday is fine but only the question is it should not cause overloading of calorie.