Amavata

Presentation on Amavata in Ayurveda and its modern co-relation with Rheumatic Arthritis.

1. PRESENTATION ON Amavata Rhumatoid Arthritis ALLPPT.com _ Free PowerPoint Templates, Diagrams and Charts Presented by:- Dr. Narendra Prasad Giri MD, Kayachikitsa , IOM, TU Nepal 2074/05/02

2. cfdjft Amavata is a conditon explained in Laghu thrayees , but not in Brihat Thrayees . First explained in Madhava Nidana , by Madhavakara who lived between 600-700AD , that is one century after Vagbhata Later books like Yoga Ratnakara , Bhaishajya Ratnavali etc quoted the slokas of Madhava Nidana to explain the disease Amavata without much change.

3. Nirukti c fd + r jft + cfdjftd \ . - laho / lIft _ cfd ] g;lxtf ] jftM cfdjftM . - laho / lIft _

4. Corelation with modern disease Most of the Ayurvedic scholars correlate Aamvata with Rhumatism especially Rhumatoid Arthritis. Some scholars correlate it with fibromayalgia .

5. Nidana & Samprapthi

6. ETIOLOGY & PATHOPHYSIOLOGY Viruddahara - means unwholesome foods or combination of foods which effects adversely. Poor digestion power, defective metabolism Sedentary life style and also too much exercise So affected defective metabolism with the influence of Vata also affects the normal functioning, and the products of this reaches Dhamanis (blood vessels) and circulates all over the body especially to the sites of Kafa and produces symptoms.

7. ETIOLOGY & PATHOPHYSIOLOGY

8. Signs These defective metabolic products with the influence of Vata produces symptoms in neck, lower back and all over the body and produces stiffness.

9. Samanya Laxyan Bodyache Poor appetite, feeling thirsty, lethargic Heavyness in the body Feverish feeling Non inflammatory and non suppurative nature

10. Ati Prabriddha Laxyan Very difficult to tolerate when becomes severe. Can also be considered as difficult to treat when aggravates Severe pain in hand, foot, head, ankle, neck, low back, knee and hip joints Pain and swelling is seen in different parts of body Pain will be severe as if bitten by scorpion . ( burning sensation and pain as if hit by stick)

11. Upadrava

12. Complications Anorexia and feeling of heaviness over the body Loss of interest/drive Bad taste in the mouth Polyurea and burning micturition Hardness in the abdomen Colicky pain Reversal of normal sleeping habbit Thirst Vomitting Giddiness Fainting Pericardial discomfort Constipation Stiffness Gurgling intestinal sounds Other complications

13. Complications Yogaratnakar added Grahani as a complication Hfgo ] T;f ]˜ lUgbf }a{No+ k|;] sf?lruf }/ jd \ . pT;fxxflg { j}/:o+ bfx + r ax'd'qtfd \ . s/f] lt u|x0fLbf]if + ljz ] iffbfd ;+1sd\ . cjSj + ; ht ] rfZr + s] jn + rfdd ]j r ..

14. Doshik involvement and Sadhyasadhyatha Dosha Involvement Pitta- Daha and Raga Vata - soola Kafa - Stimitata , Kandu and Tama Prognosis Sadhya-Ekadoshas Yappya -Two dosha involved Asadhya -All dosha involved and if inflammation is all over the body

15. Line of Management Apatarpan Langhan-Upabasa Langhan Pachan -with Dipan Pachana Medicines Dosabasechan - with Virechan and Vasti Swedan Rukshya Sweda Snigdha Sweda Upanaha Sweda Rasayan Chikitsa ( Naimittik Rasayan ) Pathya Aahar Bihar

16. Samanya Chikitsa - Bhai.Ra

17. Yogaratnakara suggests Sneha vivarjana

18. Bhaisajya Ratnawoli suggests to use Saindhawadi and Brihat Saindhawadi tel for local snehan

19. Pathya Aahar Vastuka saka Aristha Sunthi Adhrak Ajawayan Maricha Saindhav Hingu Lasun Jeerak Sahijan Parwar Karela Yava Kodrum Takra Kulathha Gomutra Usnodak Eranda taila Bihar Rukshyan Swedan Langhan Chakraman Mridu Byayam Ushna Bastra

20. Apathya Curd Fish Gaggary Milk Viruddha aahara Purvi vayu sewan Vega dharan Ratri jagaran Bathing with cold water Ati Byabaya

21. Medicines mentioned in Bhaisajya Ratnawoli Lepa Himsradi lepam Satapushpadi lepam Kwatha Rasnadi dasmoolkam Rasna saptkam Rasna panchkam Satyadi kwatham Rasnadi kwatham Maharasnadi kwatham Rasonadi kwatham Churna Amrutadi churnam Satpushpadhya churnam Hindgwadya churnam Vaishvanar churnam Punarnavadi churnam Pushpadhya churnam Aabhadya churnam Alambhuadya churnam Apar Alambhuadya churnam

22. Modaka and Pinda (Big size tablets) Ajmodadi modak Aamvatagajasimho modaka Rasona pinda Maha rasona pinda Guggulu Vatari gugglu Yograja gugglu Vrut yoga raja gugglu Vyadhi shardula gugglu Simhanada gugglu Apara Simhanada gugglu Shiva gugglu Ghrita and Taila Sunthi ghritam Shrungaveradya ghritam Kanjikashatapala ghritam Prasarni tailam Dwipanchmuladya tailam Vijaya bhairava tailam Maha vijaya bhairava tailam Vrut saindava tailam Maha saindava tailam

23. Continued… Rasa Yoga Hinguleshwar rasa Amrut manjari rasa Aamavatari gutika Aamvatari rasa Vatagajendra simha rasa Aamavataeshar rasa Triphaladi lauham Vidangadi lauham Aamapramathni vatika Aamavatadri vajra rasa Panchanana rasa lauham

24. Management of Amavata in TUATH Diagnosis of Amavata by History taking and Investigations (RF, CRP, ESR) Management- Langhan Pachan by Amapachan Medicines like Bishatinduk wati , Agnitundi wati . Doshawasechan by Virechan with Eranda Tail taken orally with warm milk Sewdan - Baluka sewdan , Rasayan Chikitsa-Vatahar Chikitsa,Aswogadha Compound, Maharasnadi kada , Aamvatari ras etc. Symptomatic treatment if necessary. Pathyapathya recommendations

25. Few researches and Findings… Effectiveness of Vaitaran Vasti and Singhanad Guggulu in comparision to Singhanad Guggulu in the management of Amavata Researcher- Dr Suresh Maharjan , IOM,TU, 2016 Sampling-Non probability, Judgement sampling n=32, 16 in each group Intervention-Group A was given Singhanad Guggulu 2g twice daily for 45 days and Group B was given Vaitaran Vasti for 8 days along with Saindhavadi tail anuvasana vasti followed by Singhanada Guggulu 2g twice daily for 45 days Results- Vaitaran vasti in combination with Singhanada Guggulu was found more effective.

26. A comparative study on Singhanada Guggulu and Trayodasdanga guggulu in the management of Juvenile Rhumatoid Arthritis WSR to Amavata . Year of Publication-2014 Researcher- Singhal et. al, Rajasthan Ayurveda University, Jodhpur Sampling-Random, n=20, 10 in each group Intervention done- Two groups each of 10 patients were formed. One group was given Sinhanada Guggulu and other was given Trayodasanga Guggulu both in a dose of 2mg/kg body weight/day for 45 days with leuke warm water. Results- Singhanaad Guggulu was found better to relieve symptoms of joint swelling, joint stiffness and joint tenderness.

27. Clinical Study on Amavata (RA) with Simhanada Guggulu and Shatapuspadi lepa . Year of Publication-2014 Researcher- Saroj Kumar Debnath et. al, Ayurveda Regional Research Institute, Gantok , Sikkim. Sampling-Random sampling, n=40 Intervention-Oral medication with Simhanada Guggulu 1 gm thrice daily with leuke warm water and Satapuspahi lepa mixed with warm water applied locally over affected joints twice daily was one for 45 days. Results-Major Improvements in 40%, Minor Improvem-ents in 50%, No improvements in 10%, Complete remis-sion in nil.

28. An Ayurvedic approach to Rhumatoid Arthritis ( Amavata )-A case study Researcher- Lekshi R. et al, Amrita School of Ayurveda ,Kerala Case study of a 58 years female with RA Treatment given- Baluka swedan for 7 days Sarbhanga Abyanga and Baspa swedan with Kotta-mchukkadi taila for next 7 days Virechaan with Moorchit Eranda Taila on 15 th day. Internal Medications- Rasnasaptak Kasayam 100ml in divided doses for 30 days + Dasamoolhareetaki Leham 1 tsf for 30 days Results-Marked improvements in signs, symptoms and blood investigations (RF, CRP, ESR)

29. Clinical evaluation on management on Amavata (RA) with Alambusadi Churna tablet, Simhanada Guggulu and Shatapuspadi Lepa . Published Year-2014 Researcher- Saroj Kumar Debnath et al, Ayurveda Regional Research Institute, Gantok , Sikkim. Sampling- Probability, n=40 Intervention-following medicines were given Alambusadi Churna tablet 500mg thrice daily for 45 days with warm milk Simhanada Guggulu 1 g thrice daily for 45 days with warm water Shatapuspadi lepa applied on affected joints twice daily for 45 days Results-Major Improvements-65%, Minor Improvements-30%, No Improvements-5%, Complete Remission-Nil

30. Rheumatoid Arthritis Introduction: Commonest inflammatory joint disease seen in clinical practice affecting approx 1% of population. Chronic multisystem disease of unknown cause. Characterized by persistent inflammatory synovitis leading to cartilage damage, bone erosions, joint deformity and disability.

31. Aetiology It is an autoimmune multisystem disorder. Genetic Predisposition- Succeptibility increases with the pre- sence of genes HLA DR4 and HLA DR1 in Indians and HLA DW15 in Japanese. Female gender is a risk factor, F:M =3:1 but before age 45 it is 6:1. Prevalance increases with age. Although Rheumatoid arthritis may present at any age, but incidence is more common in the third to fifth decade Smoking ( Current or ex-smoking) increases risk. Succeptibilty increases post partum by breast feeding? Early Menarche increases the risk

32. Relative incidence of joint involvement in RA MCP and PIP joints of hands & MTP of feet 90% Knees, ankles & wrists- 80 % Shoulders- 60% Elbows- 50% TM, Acromio - clavicular & SC joints- 30% Don’t forget the cervical spine !! Instability at cervical spine can lead to impingement of the spinal cord. Thoracolumbar, sacroilliac , and distal interphalangeal joints (DIP)of the hand are NOT involved.

33. PIP Swelling

34. Ulnar Deviation, MCP Swelling, Left Wrist Swelling

35. Extra-Articular features Constitutional symptoms ( most common)-fatigue, weight loss, anorexia and low grade fever Rheumatoid nodules (30%) Hematological - normocytic normochromic anemia leucocytosis /leucopenia thrombocytosis Felty’s syndrome- Chronic nodular Rheumatoid Arthritis Splenomegaly Neutropenia Caplan’s Syndrome- Pneumoconiosis following silica exposure Rheumatoid Arthritis

36. Rheumatoid Nodules

37. Respiratory - pleuritis , pleural effusion, pneumonitis , pleuro -pulmonary nodules, ILD CVS -asymptomatic pericarditis , pericardial effusion, cardiomyopathy , mitral regurgitation Rheumatoid vasculitis - mononeuritis multiplex, cutaneous ulceration, digital gangrene, visceral infarction CNS - peripheral neuropathy, cord-compression from atlantoaxial / midcervical spine subluxation, entrapment neuropathies EYE - kerato cunjunctivitis sicca , episcleritis , scleritis

38. Diagnosis ACR Criteria (1987 ) 1.Morning Stiffness ≥1 hour 2.Arthritis of ≥ 3 joints observed by physician. 3.Arthritis of hand joints-PIP , MCP, wrist 4. Symmetric arthritis 5. Rheumatoid nodules 6. Positive Rheumatoid Factor 7. Radiographic Erosions or periarticular osteopenia in hand or wrist joints . Criteria 1-4 must be present for ≥6 wks Must have ≥4 criteria to meet diagnosis of RA

39. 2010 ACR/EULAR Classification Criteria A score of ≥6/10 is needed for classification of a patient as having definite RA A. Joint involvement SCORE 1 large joint 2−10 large joints 1 1−3 small joints (with or without involvement of large joints ) 2 4−10 small joints (with or without involvement of large joint) 3 >10 joints (at least 1 small joint ) 5 B. Serology ( at least 1 test result is needed for classification ) Negative RF and negative ACPA Low-positive RF or low-positive ACPA 2 High-positive RF or high-positive ACPA 3

40. C. Acute-phase reactants ( atleast 1 test result is needed for classification ) Normal CRP and normal ESR Abnormal CRP or abnormal ESR 1 D. Duration of symptoms <6 weeks ≥6 weeks 1

41. Laboratory Investigations CBC ( TC , DC , Hb ) Acute phase reactants ( ESR, CRP ) Rheumatoid Factor (RF). Anti- CCP antibodies (most specific ).

42. Rheumatoid Factor/RF Antibodies that recognize Fc portion of IgG . Can be IgM , IgG , IgA 85% of patients with RA over the first 2 years become RF positive. A negative RF may be repeated 4-6 monthly for the first two year of disease, since some patients may take 18-24 months to become seropositive. It is non specific to Rheumatoid Arthritis and may be positive in other diseases such as Hepatitis C and in healthy older persons. PROGNISTIC VALUE - Patients with high titres of RF, in general, tend to have POOR PROGNOSIS and MORE EXTRA ARTICULAR MANIFESTATIONS.

43. Serum Anti Cyclic Citrullinated Peptide Antibody Sensitivity of Anti-CCPA is similar to RF but Specificity is about 95% in the diagnosis of RA. A positive test for anti-CCP antibodies in the setting of an early inflammatory arthritis is useful for distinguishing RA from other forms of arthritis. There is some incremental value in testing for the presence of both RF and anti-CCP, as some patients with RA are positive for RF but negative for anti-CCP and vice versa. The presence of RF or anti-CCP antibodies also has prognostic significance , with anti-CCP antibodies showing the most value for predicting worse outcomes.

44. Other Investigations Elevated Acute Phase Reactants ( ESR, CRP ) Thrombocytosis Leukocytosis ANA in 30-40 % Inflammatory synovial fluid Analysis Hypoalbuminemia

45. Radiographic Features Peri -articular osteopenia Uniform symmetric joint space narrowing Marginal subchondral erosions Joint Subluxations Joint destruction Collapse Ultrasound detects early soft tissue lesions. MRI has greatest sensitivity to detect synovitis and marrow changes .

46. Management Goals of Management Focused on relieving pain Preventing damage/disability Patient education about the disease Physical Therapy for stretching and range of motion exercises Occupational Therapy for splints and adaptive devices Treatment should be started early and should be individualised . EARLY AGGRESSIVE TREATMENT

47. Treatment modalities NSAIDs Steroids DMARDs Biological therapies Surgery

48. NSAIDs Non-Steroidal anti-inflammatory Drugs (NSAIDs) for symptom control : Reduce pain and swelling by inhibiting COX Do not alter course of the disease. Chronic use should be minimised . Most common side effect related to GI tract.

49. Corticosteriods in RA Corticosteroids , both systemic and intra-articular are important adjuncts in management of RA. Indications for systemic steroids are:- For treatment of rheumatoid flares. For extra-articular RA like rheumatoid vasculitis and interstitial lung disease. As bridge therapy for 6-8 weeks before the action of DMARDs begin. Maintainence dose of 10mg or less of predinisolone daily in patients with active RA. Sometimes in pregnancy when other DMARDs cannot be used.

50. Disease Modifying Anti Rhuematic Drugs (DMARDs) Drugs that actually alter the disease course . Should be used as soon as diagnosis is made. Appearance of benefit delayed for weeks to months. NSAIDS must be continued with them until true remission is achieved . Induction of true remission is unusual .

51. DMARDs Commonly used Less commonly used Methotrexate Chloroquine Hydroxychloroquine Gold( parenteral &oral) Sulphasalazine CyclosporineA Leflunomide D- penicillamine / bucillamine Minocycline/Doxycycline, Levamisole Azathioprine,cyclophosphamide , chlorambucil

52. Limitations of DMARDs The onset of action takes several months. The remission induced in many cases is partial. There may be substantial toxicity which requires careful monitoring. DMARDs have a tendency to lose effectiveness with time- (slip out). These drawbacks have made researchers look for alternative treatment strategies for RA- The Biologic Response Modifiers.

53. Biologics in RA Cytokines such as TNF- α ,IL-1,IL-10 etc. are key mediators of immune function in RA and have been major targets of therapeutic manipulations in RA. Of the various cytokines,TNF - α has attaracted maximum attention . Various biologicals approved in RA are:- Anti TNF agents : Infliximab Etanercept Adalimumab IL-1 receptor antagonist : Anakinra IL-6 receptor antagonist : Tocilizumab Anti CD20 antibody : Rituximab T cell costimulatory inhibitor : Abatacept

54. Surgical Approaches Synovectomy is ordinarily not recommended, primarily because relief is only transient. However, an exception is synovectomy of the wrist, which is recommended if intense synovitis is persistent despite medical treatment over 6 to 12 months . Total joint arthroplasties , particularly of the knee, hip , wrist, and elbow, are highly successful. Other operations include release of nerve entrapments ( e.g , carpal tunnel syndrome), arthroscopic procedures, and, occasionally, removal of a symptomatic rheumatoid nodule.