AMAVATA (RHEUMATOID ARTHRITIS) Treatment Protocol by Ayush

INTRODUCTION:

Amavata is a condition described in Ayurveda involving multiple joints, including sacroiliac joints with severe pain swelling and stiffness. General symptoms like fever, loss of appetite etc may also be associated. The disease conditions like Rheumatoid Arthritis, many other forms of connective tissue disorders like Polymyositis, Polyarthritis in elderly like Polymayalgia Rheumatica and common infective Arthritis in children like Rhueumatic Fever, Chikungunya Arthritis, Myofascial Pain Syndromes may be considered under the umbrella of Amavata.

Case Definition:

Polyarthritis associated with stiffness and associated symptoms of Ama like Angamarda (generalized body pain), Aruchi (anorexia), Trushna (increased thirst), Alasya (lassitude), Gaurava (heaviness of the body), Jwara (fever), Apaka (delayed digestive capacity) and Shunata Anganam (joint specific or generalized swelling), constipation and polyuria. Rarely the disease can manifest as monoarthritis also.

Differential Diagnosis:

• Sandhigat Jwara
• Ama Jwara

Line of Treatment

• Nidana Parivarjana should be the first line of treatment.
• Shodhana Chikitsa – Virechana, Basti, Raktamokshana
• Shamana Chikitsa - Langhana, Swedana, Rukshana, Pachana, Deepana
• External applications - Lepa, Upanaha
• Rasayana Chikitsa for Rasa
• Treatment according to Doshik involvement
• General line of treatment prescribed for Ama and Vata

LEVEL 1: AT SOLO AYURVEDA PHYSICIAN’S CLINIC/ PHC

Clinical Diagnosis: On the basis of history and clinical presentation

Investigations:

• ESR
• Complete Blood Count

Treatment: In the initial stage, Rookshana, Pachana and Deepana should be attempted with some of the following drugs.

Table 5.1: Medicines at level 1 for Amavata

*Dose can be individualized according to bowel response

The patient may also be instructed to do mild poultice fomentation with heated sand (Baluka Sweda) on the affected joints self.

Pathya - Apathya (Diet and life style education):

Since formation of Ama is the key factor in the pathogenesis of Amavata all food articles and activities leading to reduction of Agni and formation of Ama should be avoided. The patients should be always specifically instructed to stick on to light and non-fatty diet in two Annakala, preferably at morning and evening. The amount of food should be less than moderate and eat while hungry. Consumption of large amount of water while eating also is not good. Patient should avoid stress in general.

Do’s (Pathya)

• Ahara: Light diet, Panchakola Yavagu, Ushna Jala, Vegetables like Methi, Shigru, Vastuka, Karvellaka, Ardraka and pulses like horse gram (Kulattha). Crab soup, Rasona.

• Vihara: Hot water bath, sun bath, timely eating, following daily & seasonal regimen properly

Don’ts (Apathya)

• Ahara: Food articles which are heavy to digest like fried items, sweets, all dairy products except buttermilk, Dadhi, Matsya, Guda, Ksheera, Upodika, Masha, Pishta preparations made of green peas, raw vegetables and salads, pota­toes, sour food like tomato, lemon, tamarind etc.
• Vihara: Divaswapna (Day sleeping), Ratri Jagarana (night awakening), Ajirnashana (eating without the feel of appetite), overeating, Vishamashana (eating at odd timings), physical exertion just after eating, exposure to cold, sedentary life style etc are to be avoided.

Referral Criteria:

• Patients not responding to above management
• Chronic patients with complications like joint deformities, muscle wasting, anaemia

LEVEL 2: CHC’S OR SMALL HOSPITALS WITH BASIC FACILITIES

Clinical diagnosis: Same as level 1 for a fresh case reporting directly

Investigations: Same as level 1, in addition

• CRP and RF
• Radiographic evaluation – X rays of the more affected joints to evaluate the level of evolving joint deformity.

Treatment: In addition to the management mentioned in Level 1, few of the following drugs may be added

Table 5.2: Medicines at level 2 for Amavata

Inpatient Panchakarma treatment:

Swedana with Dhanyamla Dhara for 7 days, Rooksha Pinda Sweda, Nadi Sweda, Agni Lepa (external application of drugs having Ushna Virya like Tulasi, Maricha, Agnimantha, Nirgundi etc). Lepa with Dashanga Lepa or Lepa Gutika, Grihadhoomadi, Jatamayadi, Kottamchukkadi etc.

Abhyanga (external oil application) in Nirama Avastha: Visha Garbha Taila, Pancha Guna Taila, Kottamchukadi Taila, Brihat Saindhavadi Taila, Karpooradi Taila.

Pathya - Apathya (Diet and life style education): Same as level 1

Referral criteria:

• Patient not responding to above mentioned management
• Patients showing signs of severe complications
• Patients of severe chronicity who require complete Panchakarma ther­apy and Rasayana Chikitsa for better recovery

LEVEL 3: AYURVEDA HOSPITALS AT INSTITUTIONAL LEVEL OR DISTRICT

HOSPITAL / INTEGRATED AYURVEDIC HOSPITALS

Clinical Diagnosis: Same as level 1 for a fresh case reporting directly

Investigation:

• ANA (Anti-nuclear Antibody) profile to identify the specific auto immune disorder when ANA screening is found to be positive.
• Echocardiography to rule out cardiac involvement in ASO (Antistreptolysin O Titers) positive patients
• Liver Function Test to rule out disease related or drug related hepatic impairment (do at least ALT) especially to patients of RA or other connective tissue disorder who were under long term DMARD (Disease-Modifying Anti-rheumatic Drugs) or other medications.
• Renal Function Test (at least S. Creatinine) to rule out renal impairment.
• Chest X ray or CT chest to rule out Interstitial Lung Disease (ILD).
• Synovial Fluid Analysis in unresponsive mono-arthritis to rule out infective arthritis like TB or gonococcus.

Treatment: In addition to the management of Level 1 and Level -2, Panchakarma procedures indicated for Amavata can be performed.

Table 5.3: Medicines at level 3 for Amavata

Panchakarma Procedures:

Shodhana Chikitsa

1. Virechana Karma - Abhyantara Snehana with Shatpala Ghrita, Indukanta Ghrita, Shunthi Ghrita or gaughrita added with Kshara and Saindhava Lavana followed with Virechana by Trivritta Avaleha 30-100 gm, Abhayadi Modaka 2-5 tablets etc.
2. Basti – Vaitarana Basti, Kshara Basti, Ardha Matrika Niruha12

Rasayana:

• Pippali Vardhamana Rasayana13
• Bhallataka Rasayana
• Guduchi Rasayana

Pathya - Apathya (Diet and life style education): Same as level 1

REFERENCES

1. Vagbhatta, Ashtanga Hrudaya Vidyotini commentary, Chaukhambha Prakashana, Varanasi, Uttara sthana Mukharogapratishedha Adhyaya 22/102 p. no. 724.
2. Sharangdhara, Sharangdhara Samhita, Shailja Srivastava, Jivanprada Hindi Commentary, Chaukhambha Orientalia Publication, Reprint 2011, Madhyama Khanda, 6/115-119, p.no.187.
3. Nishteshwara, Parishishta Prakarana, Sahasrayogam, Chowkhamba Sanskrit Series, Varanasi, Third edition 2011, p.362.

4. Sharangdhara, Sharangdhara Samhita, Shailja Srivastava, Jivanprada Hindi Commentary, Chaukhambha Orientalia Publication, Reprint 2011, Madhyama Khanda, 2/30-33, p.no.140.
5. Sharangdhara, Sharangdhara Samhita, Shailja Srivastava, Jivanprada Hindi Commentary, Chaukhambha Orientalia Publication, Reprint 2011, Madhyama Khanda, 2/18-21, p.no.197.
6. Sharangdhara, Sharangdhara Samhita, Shailja Srivastava, Jivanprada Hindi Commentary, Chaukhambha Orientalia Publication, Reprint 2011, Madhyama Khanda, 2/88-89, p.no.149.
7. Govind Das Sen, Bhaishajya Ratnavali Siddhiprada Commentary, Chaukhambha Surbharti Prakashan, Varanasi, Agnimandya Rogadhikara 10/93-94 p. 344.
8. Govind Das Sen, Bhaishajya Ratnavali Siddhiprada Commentary, Chaukhambha Surbharti Prakashan, Varanasi, Amavata Rogadhikar 29/173-184, p. 610.
9. Govind Das Sen, Bhaishajya Ratnavali Siddhiprada Commentary, Chaukhambha Surbharti Prakashan, Varanasi, Amavata Rogadhikar 29/69-70, p.601.
10. Yogaratnakara, Vaidya Lakshmi Pati Shastri, Vidyotini Hindi Commentary, Chaukhambha Prakashan, Reprint 2013 Vatavyadhi Chikitsa, 1-3, p.no. 546.
11. Vagbhatta, Ashtanga Hrudaya Vidyotini Commentary, Chaukhambha Prakashana, Varanasi, Uttara Sthana Rasayana Vidhi Adhyaya 39/75-78, p. no.818.
12. Chakrapani, Chakradatta, Indradev Tripathi, Vaidya prabha Hindi Commentary, Chaukhambha Sanskrit Bhawan, Varanasi, Reprint 2014, Chakradatta Niruhadhikara 73/23-26, p.no. 455.
13. Vagbhatta, Ashtanga Hrudaya Vidyotini Commentary, Chaukhambha Prakashana, Varanasi, Uttara Sthana Rasayanavidhi Adhyaya 39/98-100, p. no.820.