original reasearch article - clinical...

Journal of Ayurveda Official publication of National Institute of Ayurveda, Jaipur, Rajasthan28

Background: Alcoholism is major public health problem around the world. About 10 to 15 percent alcohol users develop alcohol dependence and become alcoholic. Many people lose their life due to it either by road accident or by liver failure .To overcome this problem the present study has been conducted for the management of alcohol addiction and Alcohol Withdrawal Syndrome. Introduction: Alcohol, Acute alcoholism, chronic alcoholism and Alcohol withdrawal has been described in Laghutrayi and Brihatrayi under the heading of Madya, Mada, Madatyaya. Materials and Methods: The present clinical study on topic “Comparative study of Sameergaj Kesari Ras and Mukta Pishti with Dushi Vishari Agad in Alcohol Withdrawal Syndrome was conducted at NIA, Jaipur. 45 patients were equally allocated on the basis of inclusion and exclusion criteria both in three groups randomly. Group A were treated with Sameergaja Kesari Ras having dose 125 mg and Dushivishari Agad 5gm, BD with water after meals for a month. Group B were treated with Muktapishti 125mg, BD with water and Dushivishari Agad, 5gm, BD with honey, for a month. Group C were treated with Sameergajagaj Kesari Ras, Muktapishti and Dushivishari agad in given doses. Result: Trial Group C shows 46.66% excellent relief, followed by Group B 20% and Group A 13.33%respectively. Conclusion: Mukta Pishti has showed very significant improvement of symptom insomnia, headache. Sameergaja Kesari Ras showed significant improvement on symptom tremors. Though we do not have proved and valid drug for anxiety, insomnia and

Keywords : Alcohol, Madatyaya, Withdrawal, Craving, Agad

craving but patients were managed successfully by using the trial drugs. Inculcation of Vyadhiviprita Chikitsa and Satvavjaya Chikitsa in the patients of alcoholism will prove to be a better management modality as per ayurveda principles.

ABSTRACT

Effective Treatment of Alcohol Withdrawal Syndrome in Ayurveda

*Dr. Aarti Kondel, **Dr. Sharad M Porte, ***Prof. Anita Sharma

* Senior Ayurvedic Medical Officer, Ayurvedic health centre Kanlog, Shimla, Himachal Pradesh **Associate Professor,***Professor, Department of Agad Tantra, National Institute of Ayurveda, Jaipur, Rajasthan

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ORIGINAL REASEARCH ARTICLE - CLINICAL STUDY

Address of Corespondence:

Dr. Aarti KondelSenior Ayurvedic Medical Officer,Ayurvedic health centre Kanlog, Shimla, Himachal PradeshEmail ID : [email protected] No : 9816069330

How to Site the Article : Kondel A, Porte MS, Sharma A, Effective Treatment of Alcohol Withdraw-al Syndrome in Ayurveda, JOA XIII-1, 2019; 28 - 35

JOAjournalofayurveda.in ISSN No:2321-0435


Introduction:

Alcoholism is major public health problem around the world. About 10 to 15 percent alcohol users develop alcohol dependence and become alcoholic. Alcohol is also called Madya. Madya is oldest preparation which is mentioned in all the main text of Ayurveda including Brihartiya and Laghutrayi. As per Ayurveda Madya is nectar (Amrit)[1], if it is taken with proper manner and dose suggested by Ayurveda but it shows toxic effect if it is taken in excess doses and without following any direction suggested by Ayurveda and produce Madatyaya or Panatyaya (chronic alcoholism)[2].

In Charaka Samhita after Vishchikitsa chapter, Madatyaya has been mentioned. Chakarpani has stated that Vish and Madya have same properties therefore it is equal to vish as for its effect after excessive use is concern[3] . In Charaka Samhita Mada, Madawastha, Madataya and Dhwansaka and Vikshaya diseases are mentioned in relation to continuous use of alcohol. Different types of Madawastha (stages) are initially mentioned showing correlation between Madyapaan in specific quantity and its effect on the body, which Purvamad (first stage of Alcoholism) Madhyam Mad (3rd stage of alcoholism) has also been categorized based on the loss of Ojus Gunas due to concentration Madya in body. First is desirable and second third are avoidable.

Acharya Charaka has mentioned when the brain is affected by the action of alcohol there will be result exhilaration, ardent desire, exultation, sense of happiness and various kinds of changes according to the psychic makeup of the person and according to its Rajasic or Tamsic quality owing to excessive use of alcoholic stupor terminating in narcosis is produced[4]. This is the delusion caused by wine and is known as alcoholic intoxication. When the chronic Alcoholic addicted patients stop to drink, sudden withdrawal causes group of clinical manifestation called as Alcohol Withdrawal Syndrome. Acharya Kashyap also described this term under the heading of Panapkram[5]. Sudden alcohol withdrawal shows a set of clinical manifestation like Nausea (Hrilasa), Vomiting (Chardi), Tremors (Kampa),

Anxiety (Avsada), Agitation (Aavega), Paroxysmal sweat (Sveda), Orientation and clouding of sensorial , Hallucination (Vibrama), Headache (Shirshula).

Aims and Objectives :

¾ To evaluate and elaborate Ayurvedic aspect of Alcohol Withdrawal Syndrome

¾ To evaluate the clinical efficacy of Sameergaja Kesari Ras, Muktapishti and Dushivishari Agad in alcohol Withdrawal syndrome.

¾ Comparative study of clinical efficacy of Sameergaja Kesari Ras with Muktapishti.

Materials And Methods :

Materials

• IEC Approval: Clinical study was approved by IEC, order no. F10 (5)/EC/2014/7222 dated 7/11/2014

• Research Performa to note all information clinical demographic.

• Test Drugs Sameergaja Kesari Ras, Muktapishti and Dushivishari Agad.

• Chemicals and reagents required for various Hema-tological investigation study of drugs.

• Honorable patients, various equipment etc.

Methods

Plan of Study

Criteria of Selection of Patients

45 patients were selected randomly from OPD & IPD NIA, Jaipur on the basis of inclusion and exclusion criteria both.

They were classified in to three Groups.

1. Group A- 15 patients of Alcohol Withdrawal syndrome were treated with Sameergaja Kesari Ras 125mg and Dushivishari Agad.

2. Group B- 15 patients of Alcohol Withdrawal syndrome were treated with Muktapisht[6] and Dushivishari Agad.

Kondel A, Porte MS, Sharma A, Effective Treatment of Alcohol Withdrawal Syndrome in Ayurveda JOA XIII-1, 2019; 28 - 35


1. Group C- 15 patients of Alcohol Withdrawal syndrome were treated with Sameergaja Kesari Ras, Muktapishti and Dushivishari Agad.

Dose of drugs:

A Sameeergaj kesari Ras 125mg twice a day with wa-ter, after meal, for 30 days.

B Muktapishti 125mg twice a day with milk, before meal, for 30 days.

Duration of trial and follow up

Duration of trial-30 days

Follow up-15th day and 30th day.

Below are the tables showing the contents of drug trials in Table No. I - II

C Dushivishari Agad 5 gm twice a day with honey, after meal, for 30 days

Table No. I Showing contents of Sameergaja Kesari Ras[7]

S.No. Ingredients Latin name/English name Quantity

1. Shudha hingula Cinnaber 1 part

2. Maricha Piper nigrum 1 part

3. Shudha Ahiphena Papaver somniferum 1 part

4. Shudha Kupilu Strychnos nux vomica 1 part

Table No. II Showing contents of Dushivishari Agad[8]

S.No. Ingredients Latin name/English name Quantity

1. Pippali Piper longum 1 part

2. Dhyamak Valeriana pyrifolia decne 1 part

3. Jatamansi Nordostachys jatamansi 1 part

4. Shavar(Lohra) Syblocos Rocemosa 1 part

5. Kevati motha Cybermabilis 1 part

6. Suverchika Potassi nitRas 1 part

7. Suksham ela Elettaria Cardamomum 1 part

8. Swarangairik Yellow ochre 1 part

Inclusion Criteria

1. History of exclusive alcoholism and alcohol addiction

2. History of not taking alcohol daily now days.

3. Patients of Alcohol Withdrawal Syndrome having symptoms of Nausea, Vomiting, Tremors, Anxiety, Paroxysmal, Hallucination, Confusion.



Exclusion Criteria

1. Alcohol addicted patients suffering from liver failure, gastrointestinal bleeding, Mallory-Weiss tears, Wernicke Korsakoff’s syndrome, cerebellar degeneration.

2. Alcohol addicted patients who are suffering from major psychiatric disorders like Mania, schizophrenia and Bipolar disorder.

3. Alcohol addicted patients suffering from major systemic illness like diabetes, liver cirrhosis, MI, IHD, hypertension and pulmonary TB etc.

Withdrawal Criteria

Patients who developed seizure, severe agitation, severe anxiety, delirium tremens (DTs) after admission were withdrawer from the trial. Though nothing any happened.


4. Ageing between 20 to 60 years.

5. Both sexes.

Assessment Criteria

Criteria for Clinical Assessment of Alcohol Withdrawal Patient is as Per CIWA-AR (Nausea/Vomiting, Tremors, Anxiety, Agitation, Paroxysmal sweat, Orientation and clouding of sensorial, Tactile disturbances, Visual disturbances, Headache) and pathological assessment was assessed by LFT and Hb level.

Observation and result :

A detail Performa was created to carry out this study in a scientific way. All demographic data related to patient along with sign and symptom and of disease was noted on 1st day 15th day and 30th day of study.

Result

The assessment of the efficacy of the drugs involved in clinical trial the Clinical Institute of Alcohol Withdrawal Assessment (CIWA-AR) has been applied before and after treatment. The patients were screened by Alcohol Use Disorder Identification Test (AUDIT) and after that patients were examined 5-6 hrs of alcohol withdrawal which is called base line. The second assessment was done after 30 days of completion of treatment.

All the Results are calculated by using Software: Graph Pad In stat Version 3.10.

Intra Group comparison - For Nonparametric Data Wilcoxon matched-pairs signed ranks test was used while for Parametric Data Paired’ Test was used and results are calculated.

Inter Group comparisons, for non-parametric vari-ables, Kruskal-Wallis Test with post-test were used.

For the parametric data, One-way ANOVA with post-test was used and results were calculated.

Table No. III Showing Effect Of Therapy On Total Ciwa-Ar Score[9]

Groups N Mean MeanDif.

% of Change

SD± SE± P ResultBT AT

Group A

15 12.6000 7.2000 5.400 42.85 5.841 1.508 0.0020 VS

Group B

15 7.800 4.067 3.733 47.85 3.900 1.007 0.0020 VS

Group C

15 15.667 6.733 8.933 57.01 9.067 2.341 0.0020 VS


Table No. IV Showing Inter group comparison of Objective Parameters of all the three groups:

Objective parameters

Mean F P Result

Group A Group B Group C

Sr. BT -0.0733 0.0066 -0.0200 0.6605 0.5219 NS

Sr.BD -0.0286 -0.0400 0.0200 0.9086 0.4109 NS

SGOT 3.867 1.733 5.400 2.267 0.1161 NS

SGPT 2.00 -0.600 -1.000 3.803 0.034 S

Sr.PR 0.2667 0.03333 0.1933 1.371 0.2650 NS

Hb% -0.01333 -0.08667 -0.06667 0.1413 0.8687 NS

Table No. V Showing Cure rate wise effect of therapy

Group No. No relief0%

Mild1-25%

Moderate26-50%

Marked 51-75%

Excellent 76-100%

A 15 0 5(33.33%) 2(13.33%) 6(40%) 2(13.33%)

B 15 0 5(33.33%) 1(6.66%) 6(40%) 3(20%)

C 15 0 6(40%) 1(6.66%) 1(6.66%) 7(46.66%)

Group -A: In this group 0% patients were of no relief, 33.33% patients were of mild relief, 13.33% patients were of moderate relief, 40% patients were of marked relief and 13.33% were of excellent relief.

Group -B: In this group 0% patients were of no relief, 33.33% patients were of mild relief, 6.66% patients were of mod-erate relief, 40% patients were of marked relief and 20% were of Excellent relief.

Group -C: In this group 0% patients were of no relief, 40% patients were of mild relief, 6.66% patients were of moder-ate relief, 6.66% patients were of marked relief and 13.33% were of excellent relief.


Figure No. I Showing Cure rate wise effect of therapy



Discussion:

In Ayurveda all the Acharyas including Charaka, Sushruta, Vagbhata, Kashyapa, Madhav have described Mada, Madya, Madatyaya in detail though there is some variation of nomenclature & clinical manifestation. According to Sharangdhar Samhita the substance which affects brain and mind after ingestion is called Madya. Acharya Charaka, Sushruta and Vagbhata have described three stages of Mada Purva, Madhya and Pashchim while Madhavkar describes four stages i.e. Purva, Madhya and Pashchim and intermediate stage between the second and third stage, he considered this stage separate stage.

Consumption of Madya since long time inadequate dose and inadequate manner produces chronic toxic effect on human body called Madatyaya.[10] Acharya Kashyapa has described the term Panapkram which produce some clinical manifestation due to sudden stop of alcohol, but the clinical manifestation are not mentioned in detail. The clinical manifestations are not mentioned in Laghutrayi & Brihatrayi.

Acharya Vangsen has stated that the physical dependency of alcohol remains up to one week which is nearly similar to the description of Harrison’s principles of Internal Medicine which has mentioned that the withdrawal symptoms generally begins within 5-10 hrs. of decreasing ethanol peak in intensity on day 2nd or 3rd and improve by day 4th or 5th but anxiety &insomnia ,mild level of autonomic dysfunctions may persist to some degree for more than six month as protracted abstinence syndrome which is not similar to our Acharyas.

Acharya Charaka has also stated that the people having Jitendriya in Prakriti means which has controlled over all the Indriyas (sense organs) is not affected physically and mentally even after sudden withdrawal of alcohol .But now a day’s most of the people are not Jitendriya, they do Mithya Ahar-vihar and even don’t take Madya in adequate dose & manner as described in Ayurveda. This produces chronic alcoholism, dependence and physical, mental clinical manifestation after sodden stoppage of

alcohol.

Acharya Charak further recommended Harshini Chikitsa means musical, motivational & recreational therapy and Mano Vaigyanik chikitsa (according to Charaka) means psychological treatment during the treatment of Madatyaya .It means that they knew that sudden withdrawal will affect the human body mentally as well as physically and produce physical symptoms like nausea, vomiting, tremors and mental symptoms like anxiety, agitation, hallucination due to sudden stoppage of alcohol.

Probable Mode of Action Of Drugs: Sudden alcohol withdrawal shows a set of clinical manifestation like Nausea (Hrilasa), Vomiting (Chardi), Tremors (Kampa), Anxiety (Avsada), Agitation (Aavega), Paroxysmal sweat (Sveda), Orientation and clouding of sensorial , Hallucination (Vibhrama) ,Headache (Shirshula).The Ushna, Teekshna, Ruksha Guna of the contents of Sameergaja Kesari Ras and Dushivishari Agad cleared the connecting channels (Srotasa) like Udakavaha, Swedavaha and Annavaha in the body which were vitiated in this disease.

This resulted in increase of appetite, slowed down the sweat, and curbed the headache. The Nidrajanaka (Sedative effect) and Vatshamaka (Vata pacifying) effect of drugs synergistically controlled tremors, anxiety, agitation and hallucinations in the patients. The Pittashamaka (Pitta pacifying) effect of Muktapishti controlled vomiting in the patients.

Conclusion: Addicted patients pester from place to place due to ineffective management techniques. Ayurveda the science of life has a holistic approach towards management of any individual as a whole. Instead of viewing the individual as a list of symptoms the focus is on their full physical, mental, and spiritual health. This way of approaching things is based on the idea that the symptoms of ill health are due to imbalances in the body, and if balance can be restored the symptoms will go away. Conventional methods tend to focus predominately on symptoms (though of course with attempts to understand


References

1. Agnivesha: Charaka samhita, revised by Charak and Dridhabal, with commentary of chakrapani¬datta, edited by jadavji trikamji acharya, chauk¬hambha Sanskrit Sansthana, Varanasi. Chikitsa Sthana, Chapter 24 verse 07, 5th Edi. Reprint 2011p.582

2. Agnivesha: Charaka samhita, revised by Charak and Dridhabal, with commentary of chakrapani¬datta, edited by jadavji trikamji acharya, chauk¬hambha Sanskrit Sansthana, Varanasi. Chikitsa Sthana, Chapter 24 verse 88, 5th Edi. Reprint (2011)p.587

3. Agnivesha: Charaka samhita, revised by Charak and Dridhabal, with commentary of chakrapani¬datta, edited by jadavji trikamji acharya, chauk¬hambha Sanskrit Sansthana, Varanasi. Chikitsa Sthana, Chapter 24 verse 60, 5th Edi. Reprint (2011)p. 585

4. Agnivesha: Charaka samhita, revised by Charak and Dridhabal, with commentary of chakrapani¬datta, edited by jadavji trikamji acharya, chauk¬hambha Sanskrit Sansthana, Varanasi. Chikitsa Sthana, Chapter 24 verse 206, 5th Edi. Reprint (2011)p. 591

5. Sharma H. Kasyapa Samhita of Vridha Jivaka. Reprint ed. Vara-nasi: Chaukhamba Sanskrit Sansthan, Chikitsa Sthana: Chapter Verse53.p.271

6. RasatantRasara And Sidhaprayoga Sangrah: Part I,Krishna Gopal Grantha Mala, Mukta Bhasm prakarn 26, year2003, pg 183 - 86

7. RasatantRasara And Sidhaprayoga Sangrah: Part I,Krishna Gopal Grantha Mala, Kharliya Rasayana 89, Sameergaja Kesari Rasa, year2003, p. 463-465

8. Sushruta: Sushrutsamhita, with commentary of Dalhana, Edited by Vaidya Jadavaji Trikamaji Acharya, chaukhambha orientalia, Varanasi.8th edition. Kalpasthana 2:51-52, p.514 (2005)

9. Objectifies alcohol withdrawal symptoms to help guide therapy: CIWA-Ar for Alcohol Withdrawal, mdcalc.com, http://www.md-calc.com/ciwa-ar-for-alcohol-withdrawal/

10. Agnivesha: Charaka samhita, revised by Charak and Dridhabal, with commentary of chakrapani¬datta, edited by jadavji trikamji acharya, chauk¬hambha Sanskrit Sansthana, Varanasi. Chikitsa Sthana, Chapter 24 verse 88, 5th Edi. Reprint (2011)p.587


causes). This approach has proved to be fruitful in many ways, but it can leave the individual feeling as if they have been treated as a problem. Overcoming an addiction can be a real challenge for people. The patients in all the three groups were symptomatically relieved and the drugs used were able to break down the pathogenesis of the disease in more than one way.

The alcohol addiction involves both Sharirika and Mansika Prakriti. The Vatapitta Prakriti and Rajasa Prakriti were predominantly found among all the patients. The Srotas involved predominantly were Udakvaha, Swedvaha, Annavaha and Manovaha. The drug Mukta Pishti showed very significant improvement in symptom insomnia and headache. Sameergaja Kesari Ras showed significant improvement on symptom tremors. There were no significant side effects, adverse reactions and complications of trial drugs (Sameergaja Gaj Kesari Rasa, Mukta Pishti and Dushivishari Agada) during the entire study.

Though we do not have proved and valid drug for anxiety, insomnia and craving but patients were managed successfully by using our trial drugs . Ayurveda medicine states that it is the inability to deal with stress that leads to substance abuse but knowledge of this is usually not enough to end the problem. This is because the individual becomes physically as well as psychologically addicted to these substances. Considering the fact that the mental faculty of the patient can be dealt with many ayurvedic medicines given in the classics, one must offer the Satvavajaya chikitsa to such type of patients.

Recommendation: As study was conducted over small group of patients, a similar study performed over a large sample at multicenter could have presented more accurate results.

Acknowledgement: The author is very grateful to the Director of NIA, Jaipur where the present trial was conducted fruitfully and the patients who actively took part in the research trial.

Conflicts of interest: None.



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