Madhumeha (Diabetes) Management

Prof. Dr. K. Shiva Rama PrasadDept. of Kayachikitsa (PG)PGARC, DGMAMC, [email protected]

In the Memory of VVS Sastry

20-11-1932 to 12-08-1999

13-8-2007 [email protected] 2

A step towards healing

Sharing of the information of Madhumeha in front of many intellectuals of Ayurveda is a Herculean TaskGnosis of Diabetes makes ones to attend it either curative or prophylaxes forms.Nosology of Madhumeha is necessary to manage it full length. Apart from many classifications - Susruta 7 fold classification has much importance to understand the disease Madhumeha.


7 fold classification of Madhumeha

Adibala PravruttaJanmabala PravruttaDoshabala PravruttaSanghatabala PravruttaKalabala PravruttaDaivabala PravruttaSwabhavabala Pravrutta

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Adibala PravruttaMatruja Madhumeha – probably developed because of Matruja beeja avayava Medo vikruti – kostanga – kloma(Pancreas-?) Pitruja Madhumeha – Asthi beeja avayava – Acetylcholine –citrus acid cycle disturbance – neo glycolysis - ketone bodies Genetically influenced Madhumeha – where Beeja – Beejabhaaga avayava are influenced to give rise MM child The genetics and involvement of Genes are even though not new – medically to treat a patient of Shisava MM is not possible. But “Eugenics” – is provided by the Ayurveda to combat the disease to eradicate or to avoid “predominance” of Beeja –Pumsavana - sadvrutta etc. Apart from this the colonial prophylaxis management as –Atulya Grotriya is followed.

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Janmabala PravruttaRasakruta (Apatarpanajanaya MM) & Douhrudapacharaja (Santarpanajanya MM) Rasakruta MM is, where mother irregular food habits or lack of food or incapacities of taking food leaves an impression over the baby to develop accumulation of food for future use habituated to develop as Juvenile DM. – 2nd World war impression over German population Douhrudapacharaja literally mother’s deviated habits influence the baby for deranged segregations of Shareera Kleda (Blood Sugar) to develop JDM as result of impaired metabolic functions

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Doshabala Pravrutta

Amashaya Samutha MM & Pakwashaya Samutha MM We always behind the Dosha and Dhatu, which are altering all the time to target for any illness in the body. Off course the Dosha are dependent over the food and digestion. The pre digestive manifested MM and post digestive manifested MM has to be differentiated before treatment

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Sanghatabala Pravrutta

Shastra (armed fight) and Vyala(animal) should be concerned to exogenous causes of MMViral DM is said to be a new invention in contemporary but the Krimija MM even though not classified, its existence is proved through usage of Anti retroviral management in MM.

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Kalabala Pravrutta

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Seasonal influences are common in manifestation of disease. This cause Agni disturbances. The MM of seasonal variations dependent on food habits which are of external causes implies influence on shareera kleda to cause Amashaya samutha MM with apakwa rasa kleda. In some seasons sugar levels alters to high and low even – as we see in summer hypoglycemia – so as the usage of madhura rasa


Daivabala PravruttaIn it Vidud-ashanikruta – is said to be any external shock referred to execute electrical impulses that disturb the body environment and cause Hyper or Hypoglycemia Pishacha once again fingers towards the infectious origins - which could be sudden or communicated viral or Bacterial origins could occur either by contact or epidemiological or transfusion nèù´É¤É±É |É´ÉÞkÉÉ ªÉä näù´ÉpùÉä½þnùÊ¦É¶É{iÉEòÉ: +vÉ´ÉÇhÉEÞòiÉÉ ={ÉºÉMÉÇVÉÉ¶SÉ iÉä +Ê{É ÊuùÊ´ÉvÉÉ: Ê´ÉtÖnù¶ÉÊxÉEÞòiÉÉ: Ê{É¶ÉÉSÉÉÊnùEÞòiÉÉ¶SÉ - {ÉÖxÉ¶SÉ ÊuùÊ´ÉvÉÉ: - ºÉÆºÉMÉÇVÉÉ: +ÉEòÎº¨ÉEòÉ¶SÉ



Swabhavabala Pravrutta

In this the diseases manifested during the un time/time schedule routine course pathological conditions are discussed – like gestational DM etc which may ultimately leads to precipitate MM/DM permanently as markerIn the old age hypoglycemia (Vata) and children with hyperglycemia (Kapha) are common

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Sahaja MM

Sahaja MM is Krusha – Rooksha – Alpashi– Always Parisarana sheela (hyperactive) -is not indicated with any elimination but to treat with “Samskruta Annpana” pathya –transformed food regulations and Samshamana chikitsa – palliative management – along with diseases or conditions associated to even treat is indicated.

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Apathyanimittaja MM

Apathya nimitta MM is Sthoola –snigdha – wants comforts of food and sleep – is to be treated with Apatarpana Chikitsa – Samshodhana following the “Samutha Vishesha” as either with Vamana in case of Amashaya samuthaand Virechana fro Pakwashaya samutha MM

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Vamana – Virechana – Vasti with Alpa sneha and preferably with Ghruta (Medo- Kapha-Vata haraChikitsa) Sneha pacifies Vata and Medohara Kaphahara Kashayaare releave MMIn all MM methods of management are –Baddhamootrani – Amedaskarani –Brumhana – Agni deepana – Bala janana annapaana – Kleda prashamanadravya– Medoprahsmana dravya -´ÉÉ¨ÉªÉäiÉÂ - |ÉMÉÉføÊ´É®äúSÉªÉäSSÉ - Eò¡ò¨Éä½äþ ´ÉÉ¨ÉªÉäiÉÂ - Ê{ÉkÉ¨Éä½äþ Ê´É®äúSÉªÉäiÉÂ - +É¨É¶ÉªÉºlÉä Eò¡òÊ{ÉkÉä ´ÉÉ¨ÉªÉäiÉÂ - {ÉC´ÉÉ¶ÉªÉºlÉäÊ´É®äúSÉªÉäiÉÂ - - - +ÉºlÉÉ{ÉªÉäiÉÂ ÊxÉºiÉè±ÉäxÉäÊiÉ ´ÉSÉxÉÉnù±{ÉPÉÞiÉÉ¦ªÉxÉÖYÉÉxÉ¨ÉÂ - +±{ÉºxÉä½þÉlÉÇ¨ÉxªÉä - ºÉÖ¸ÉÖiÉ ÊSÉÊEòiºÉ 11/7 b÷±½þhÉÊºÉrùÉÊxÉ iÉè±ÉÉÊxÉ PÉÞiÉÉÊxÉSÉè´É näùªÉÉÊxÉ ¨Éä½äþ¹´ÉÊxÉ±ÉÉi¨ÉEäò¹ÉÖ¨Éänù: Eò¡ò¶SÉè´É Eò¹ÉÉªÉªÉÉäMÉè: ºxÉä½èþ¶SÉ´ÉÉªÉÖ: ¶É¨ÉªÉäÊiÉ iÉä¹ÉÉ¨ÉÂ - SÉ®úEò ÊSÉÊEòiºÉ 6/34¨ÉÚjÉÉªÉ¨ÉänùºÉäSÉ Ê´É{ÉÊ®úhÉ¨ÉiÉä - iÉº¨ÉnùºªÉ iÉäVÉÉävÉÉiÉÖ ´ÉÞqùªÉä C±Éänù¨Éänù: |É¶É¨ÉxÉÉªÉSÉ ¤ÉÊ±ÉxÉ: ºÉÆ¶ÉÉävÉxÉÉÊxÉ |ÉªÉÖÆVÉÒiÉ - - -- ºÉ´ÉÇºªÉSÉ ¤Érù¨ÉÚjÉÉhªÉÉ¨ÉänùºEò®úÉhªÉ ¤ÉÞÆ½þhÉÉxªÉÎMxÉnùÒ{ÉxÉÉÊxÉ ¤É±ÉVÉxÉxÉÉÊxÉ +zÉ{ÉÉxÉÉÊxÉ -+¹]õÉÆMÉ ºÉÆOÉ½þ ÊSÉÊEòiºÉ 14/2


Murphy's Fourth Law states that - If there is a possibility of several things going wrong, the one that will cause the most damage will be the one to go wrong. “Management” rather than “treatment”, is the appropriate term in MM/DM, and involves diet, regulations, exercise, insulin, oral hypoglycemic, patient education and counseling.


Points of observation @ MM

Sahaja meha (Beejadosha) - krusha MMApathyanimittaja - sthula MMAmashaya Samutha MM indicated with Vamana even (Kapha or Kapha Pitta MM)Pakwashaya samutha MM indicated with Virechana (Pitta MM) Avruta Vata janaya MMDhatu kshaya Janya MM Krimija MMGarbhini MMChintajanya MM, etc.

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Prabhoota (more than 4 Anjali - Dushyadravibhootata) – Avila (Samala) - Madhura(Kleda- Ojas) Mootra as common symptoms are developed due to – Shareera kleda (blood sugar) added to urine as – glycosuria is “Pratyatma Niyata Lakshana” requires management Usually the MM patient is with – impaired Agni where in pathology has transformed meda as mootra and the tejas of it augment Kleda with Abhishyanna Deha – Drava Pradhana deha

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In a nut shell - Ahara consumed Absorbed from Amashaya (Madhura rasa ahara) = Amashaya samutha MM = Vamana indicatedFood absorbed and transformed at Pakwashaya (Madhuravipaka ahara) = Pakwashaya samutha MM = Virechana indicatedRasa nimittaja or santarpana janya or Apathya nimittaja MM is pathological state of excess rasa in shareera as (Dhatu vruddhi) understood as intracellular glucose excess (many times we are not considering this condition) Excess is mala always – so the excess rasa from the dhatu is brought in to system (interstitial glucose excess) to name as –Shareera Kleda (Blood glucose) Shareera kleda along with “Apdhatu” is filtered by Mootravahasrotas to get Madhura Mootra where the re-absorption capacities of “Vrukka” or Shareera is failed Excess kleda (glucose) attracts 16 molecules of water so as to get Prabhoota and Avila Mootra in MM – thus the Baddhamootra drvaya along with Amedaskara as palliative management


Preparations Used In Prameha

Swarasa –AmalakiHaridraNimbapatraBilwapatraGuduchi

Kwatha : VidangadiPhalatrikadiMustadiManjishthadiPathadi

Churna : TriphaladiMustadiGokshuradiArkadi

Ghrita: Dhanvantar ghritaTrikantakadi ghritaSinhamrita ghritaDadimadi ghritaShalmali ghrita


Gutika : ChandraprabhaIndravatiPramehantak Vati

GuggluGokshuradi Guggulu

ModakaKastur Modaka

AvlehakushavlehaBangavleha

PakaPugapakaAshwagandhadi pakaDraksha Paka. Asava Arishta:

LodhrasavaDantyasavaMadhukasavaDevdarvyadiarishtaLodhrarishta.

Rasaushadhi: Vasant kusumakar RasaMehamudgar RasaBrihat Vangeshwar RasaPrameha gajkesri RasaTrivanga BhasmaVasant tilaka Rasa.


Pathya in Madhumeha(Low caloric diet)

Shook Dhanya: Jeerna Shali, Shashtika, Kodrava, Yava, Godhuma, Uddalaka,ShyamakaShimbi Dhanya:Chanaka, Adhaki, Kulattha, MudgaShaka Varga: The leafy vegetables with a predominance of tikta-kashaya rasa, Patola, Karvellaka, ShigruPhala Varga: Jambu, Dadima, Shringataka, Amalaki, Kapittha, Tinduka, Kharjura, Kalinga, Navina Mocha.


Mamsa Varga:Vishkira mamsa,Pratuda, Jangala mamsaTaila Varga: Danti, Ingudi, Sarshapa , AtasiUdaka Varga: Sarodaka,Kushodaka,MadhudakaKritanna Varga: Apupa,Saktu,Yavodana,Vatya,YushaOthers: Madhu, Hingu, Saindhava, Maricha, Lasuna


Pathya Vihara

To have walk as much as possible traveling on elephants, horses different plays and gamesdifferent forms of marshal arts practiceroaming in different places other than temples using umbrella Following “Sadvrutta”


Apathya in Madhumeha(High caloric diet)

Aahara: Jala, Milk, Ghee, Oils, Curd, Sugar, Different types of rice preparations, anupa, gramya and audaka mamsa, Ikshurasa, Pishtanna, Navanna.Vihara: Eksthana asana, Divaswapa, Dhoompana, Sweda, Raktamoksha, Mutravega dharana.


Madhumeha Chikitsa

Baladi Churnam – Kshaya - Harita Samhita Gokantkadyavaleha – Bhava PrakashaKharpara rasayanam – Rasa Ratna samucchyayaManjisthadyam Ghrutam – Gada NigrahaSinhamrut Ghrutam – ChakraduttaKhadirradi Kashaya – GadanigrahaPashanbhed Kashaya – Sahasra YogaPashanbhed Pak – Yoga RatnakaraAsanadi Yoga - Bhava Prakasha


Indravati – Rasendrasara sangrahaVedvidya vati – Bharata Bhaishajya Ratnakara Vol 4 Bahumootrantaka ras – SahasrayogaMaskmruganka ras – Rasaraja sundaramMeha Kesari ras – Rasendra sara SangrahaPramadananda ras – Bruhat yoga TaranginiSarweshwar ras – Bhaishajya RatnavaliSomanath ras – Rasendra ChintamaniVangeshwara ras – Yoga RatnakaraTaala Maranam – Bharata Bhaishajya Ratnavali vol-2Umashambhu Ras – Rasa Ratna samucchya283 Rasa yogas act on Prameha among 686 yogasExclusive Madhumeha hara yogas are 21


Madhumeha

Shareerika Manasika

Chintajanya

SahajaBeejadosha

ApathyaNimittjaSthula

Amashaya Samutha

Pakwashaya Samutha

•Krimija

•Douhrudadosha

Anya

Krusha


Revalidation of ManagementTwo entities viz. Shareera Kleda Vruddhi(Hyperglycemia) and Madhura Mutra(Glycosuria) are specific w.s.r. to Madhumeha management. Increase in blood glucose depends upon the tolerance and threshold of body and the action counter depends upon the Vikara vighata bhavain the body Urine out put with sugar is lack of re absorption capacity of kidney The management is proposed - based upon the level of pathology embedded in Amashaya (Pancreatic) or Pakwashaya (Renal) influence


In Amashaya Samutha MM –Excess glucose absorption from Amashaya because of –Navanna, Guda vikruti etc. makes initially temporary increase of glucose levels there by the Santarpanothavikara MM develops. The MM from Amashaya is combated from regulating food – use of Pathya Ahara and medicines that inhibit the absorption of glucose from stomach Best example to block glucose absorption is “Indrayava”and “Apamarga Tandula”Here the importance of Vata regulation plays an important role in terms of regulating the pancreas. We should not only see that the shareera kleda is re absorbed from Henley's loop but also re absorption from gut – which could be controlled by controlling the Vyanavata


Pakwashaya Samutha MM is a condition which is developed because of the post digestive metabolism or protein/fat transformation or at the interference of Citrus acid cycle which in turn excreted through kidney Mainly the action which regulate the fat metabolism and additional glucose release in to the blood as “Shareera Kleda” has to be controlled by either burning it or eliminating it. Here the management which is said is –Virechana – Mootra virechana. Such as Asana –Pashanabheda – Punarnava etc. along with Anulomana – Virechana for Vata


Krimija Madhumeha – a uncommon name –practically observed should be treated by the Krimihara – pramehahara – medohara –Brumhana – Amedskara such as – (used in Prameha & Madhumeha management) Nisha – Amalaki – Akuli combination The drugs such as – Vidanga etc.The drugs acting on skin – Manjista etc

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Dhatukshaya janya MM managed with the Dhatu Pusti kara bhavasAvaranajanya MM treated by controlling Vata Chintajanya MM pacified by controlling Vata, counseling and relieving from causative factorsVastijanya MM (Hexosis) (defect of Hexosetransport or active Na+-glucose co-transporters (SGLT) and the facilitative glucose transporters) even though not new a condition, where the glycosuria is observed with out rise of blood sugar –shareera kleda because of filter disturbances in the kidney In the management of MM the role of Vanga and Vatsaka are memorable


Present trends of utilising hypoglycemic agents to regulate the disease may give temporary hypoglycemic conditions but the understanding of the “Vikara Vighata Bhava”and utilising them in right way offers the MM management in full length. Much to confer on Madhumeha and Diabetes and to unveil – a never end saga It is my privilege to speak on this topic at “World Diabetic Capital” - Hyderabad

Health & Medicine

Madhumeha (Diabetes) Management