• Abstract: Amavata is a disease in which vitiation of Vata Dosha and accumulation of Ama take place in joint(s), and it simulates rheumatoid arthritis (RA) at modern parlance. Shamana (conservative) and Shodhana (biological purification of the body) treatments are advised in Ayurveda whereas anti-inflammatory, analgesics, steroids, and disease-modifying antirheumatic drugs are required for its management as per modern medicine, which are not free from side effects. A female was suffering from multiple joints pain with swelling, severe morning stiffness, restricted movements, malaise, and Mandagni (poor appetite) for the past 1½ year, which was classified as Amavata/RA (having 7/10 score as per the RA classification criteria, 2010). After Deepana-Pachana and Snehapana, Virechanakarma was done by the administration of Trivrita Avaleha and castor oil. The assessment was made on the basis of relief in signs and symptoms and serological findings of RA factor, C-reactive protein (CRP), immunoglobulin E (IgE), and erythrocyte sedimentation rate. After Virechanakarma, RA factor reduced from 94.0 IU/ml to 50.0 IU/ml, CRP reduced from 22.7 mg/L to 1.8 mg/L, and IgE was reduced from 680 kU/L to 53.7 kU/L, with remarkable reduction in joints pain and swelling. Further, by avoiding specific Nidanas, i.e., known allergens for food, drugs, and inhalants, the patient has relief in almost all signs and symptoms for the past 1 year of follow-up with least medications. This single case report highlights that Amavata/RA can be managed with appropriate diet regimen, Virechanakarma and can be managed effectively with minimum requirement of medicines.

1. Introduction

Amavata is a disease in which vitiation of Vata Dosha and accumulation of Ama take place in joints, which simulate rheumatoid arthritis (RA) in modern parlance.^[1] Ama is a maldigested product, which is not homogeneous for the body. Whenever that Ama gets localized in the body tissue or joints, it can lead to production of pain, stiffness, swelling, tenderness, etc., in the related joints.^[2] The features of Amavata are much identical to RA, an autoimmune disorder which causes chronic inflammatory and symmetrical polyarthritis.^[3] In Ayurveda, Nidana Parivarjana (avoidance of causative factors) is considered as the first and foremost line of management for any disease. Virechanakarma is a Shodhana process (biological purification of the body) to balance the vitiated Dosha in general and Pitta Dosha in particular.^[4] Hence, this study included both the treatment modalities, i.e. Nidana Parivarjana and Virechanakarma to manage Amavata effectively.

2. Case Report

A 45-year-old female having 60 kg body weight, housewife, of Vata-Pittaja Prakriti, residing in an urban area, suffering from multiple joints pain visited the outpatient department of Panchakarma for Ayurvedic treatment. The patient was suffering from multiple joints pain of the second and third metacarpophalangeal joints and second and third proximal interphalangeal joints of both hands along with swelling, severe morning stiffness, restricted movements, malaise, and Mandagni (poor appetite) for the past 1½ year.^[5] The sleep was also disturbed as pain was increasing at night. Sometimes, symptoms were so severe that the patient was unable to stand or walk even after taking strong pain killers.

There was a history of occasional joints pain since 2009, and most of the times, it was mild in nature and rarely required any anti-inflammatory or analgesic drugs. A single dose of nonsteroidal anti-inflammatory drug tablet was sufficient for pain relief whenever it was required. Such pain was felt in any joint which was shifting in nature and increased during rainy and winter seasons. There was no history of any addiction/treatment/illness except the history of cesarean section for two children in 1993 and 2001, uneventfully.
The patient was diagnosed as a case of Amavata provisionally on the basis of the clinical signs and symptoms. The diagnosis was confirmed by performing routine blood investigations and some specific investigations such as rheumatoid factor, erythrocyte sedimentation rate (ESR), immunoglobulin E (IgE), and C-reactive protein (CRP), which was classified as Amavata/RA (having 7/10 score as per the RA classification criteria, 2010) [Table 1]. The allergy screening test was also carried out and allergy was reported with carrot (+++), dal chana (+++), lemon (+++), coconut (++), almond (++), yeast (++), house-dust-mite (+++), Aspergillus fumigatus (+++), perfume (++), aspirin (++), ibuprofen (+), and diclofenac (++). As the patient did not get any relief with Shamana Chikitsa (ayurvedic or modern medicinal treatment), it was decided to go for Shodhana Chikitsa (Panchakarma). The patient underwent Virechanakarma (therapeutic purgation) as per indication mentioned in the classics of Ayurveda.^[6],[7]

Table 1: Assessment before and after treatment

The patient underwent Virechanakarma in December 2013. First of all, Deepana-Pachana was initiated with Amapachana Vati, 500 mg, thrice a day for 1 week followed by Shunthi Churna, 3 g, thrice a day with warm water for 1 week. After that, Snehana was started with an initial dose of 40 ml of cow ghee, once a day followed by light diet after proper digestion of the ghee. The amount of ghee was increased by 20 g daily up to 120 g on the 5^th day as per the protocol of Snehana. Swedana Karma was started by 6^th day for 3 consecutive days after the appearance of symptoms of Snehana on the 5^th day. Swedana was done once daily in the morning by performing whole body fomentation in a special Swedanabox after Bala Taila Abhyanga (body massage). Virechanakarma was done by administration of 100 g Trivrita Avaleha and 20 ml castor oil at 10 am (Pitta Kala) on the 9^th day. About 3 h later, Virechana Vega was started, and total 15 Vega (passed stool) were observed till the evening. From 10^th day onward, Sansarjana Krama (a process of resuming normal diet) was started by prescribing Peya (preparation of rice and water) and Vilepi (preparation of rice) and so on successively for 3 days. From 4^th day onward, diet with least spices was suggested. After completion of the Sansarjana Krama, by 7^th day the patient was put on the routine diet. Care was taken not to consume the known allergic food (as per the allergy report) and other allergic things reported in the test.

After completion of Virechanakarma, the patient felt 40% relief in pain and stiffness of the joints. The requirement of anti-inflammatory and analgesic drugs (indomethacin and tramadol) was reduced to 50%. The patient was getting sound sleep after taking one tramadol capsule of 100 mg, at night. Meanwhile, the patient was screened for allergy with food, drugs, and inhalants by sending blood sample to endocrine laboratory, Ahmedabad. After knowing the findings, all known allergy-causing foods, drugs, and inhalants were restricted in routine usage as for as possible. The patient was feeling much relief gradually. After 3 months of Virechanakarma and on adopting the usual routine food except foods and drugs known for allergy, the patient felt significant relief in the signs and symptoms of Amavata. The patient was followed up by every 15 days for 6 months, and then, every month for further 6 months to observe the recurrence of the symptoms. After follow-up of 1 year, the patient was found free from almost all signs and symptoms of Amavata. The quality of life was improved significantly and the patient was enjoying a normal healthy life with no exacerbation.

In this case study, the assessment was done on the basis of signs and symptoms as well as serological tests for RA factor, CRP, IgE, and ESR estimation. Before Virechanakarma, RA factor was 94.0 IU/ml, which reduced to 50.0 IU/ml after Virechana. CRP level was also reduced to 1.8 mg/L from 22.7 mg/L after avoiding specific Nidanas, i.e. known allergens (food, drugs, and inhalants). The value of IgE was reduced from 680 kU/L to normal range (53.7 kU/L) after 3 months. This indicates that after the Virechanakarma and restriction of the foods, known for allergy, increased immunity was observed and relief was noted. No change was observed in ESR value though other biochemical parameters showed remarkable changes.

3. Discussion

Virechanakarma is described for the effective management of Amavata as a Shodhana therapy. As it is the most suited therapy for the Sthanika Pitta Dosha, it might be responsible for Agnivardhana and evacuation of Ama, which is the main culprit of this disease.
In this case, although RA factor is still high (50.0 IU/ml), yet there is no clinical feature of RA/Amavata, which suggests that only increased level of RA factor may not be sufficient to cause features of RA/Amavata unless some aggravating factors in the form of food/drugs/allergens associate to initiate the process. Significant symptomatic relief was observed, and no need of medication in the follow-up period of 1 year was required. At present, the patient is almost free from all signs and symptoms and she is enjoying comfortable life by carefully avoiding the known allergens/dietary substances/drugs.

3. Conclusion

Virechanakarma followed by the Vishishta Nidana Parivarjana in the form of food and drugs showed remarkable symptomatic relief in the features of Amavata. This observation needs to be studied in more number of patients for better opinion to manage Amavata/RA.

Acknowledgements

The authors thank Prof. M.S. Baghel, Ex-Director, I.P.G.T. and R.A., Gujarat Ayurved University, Jamnagar, for providing support to the study.

Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.

References

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About Authors: Sanjay Kumar Gupta & Tukarama S Dudhamal - Department of Shalyatantra, Institute for Post Graduate Teaching and Research in Ayurveda, Gujarat Ayurved University, Jamnagar, Gujarat, India. Anup B Thakkar and Aditya Neema - Department of Panchakarma, Institute for Post Graduate Teaching and Research in Ayurveda, Gujarat Ayurved University, Jamnagar, Gujarat, India.

Article available online/offline on: AYU, Vol. 36, Issue 4, Oct-Dec 2015, Page no.413-415, for more details please visit: www.ayujournal.org

Address for correspondence: Sanjay Kumar Gupta, Head, Dept. of Shalyatantra, I.P.G.T. and R.A., Gujarat Ayurved University, Jamnagar - 361 008, Gujarat India.

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