PRAMEHA – AN APPROACH BASED ON PATHOPHYSIOLOGICAL MECHANISMS

Dr K P Yadunandanan MD AyMedical OfficerGovt Ayurveda HospitalChelembra, Malappuram Dist

Our SpecialitiesFrozen ShoulderOA KneeTennis ElbowCTSLeg PainFeet NumbnessErectile Dysfunction

Ayurveda & DiabetesDiabetes = PramehaNisakathakadi or

KathakakhadiradiNirooryadiMehari powdersPaneeyams “Ayurvedic = Herbal Hypoglycemic

Drug”“Lack of a proper understanding of

disease & treatment approach”

Disease Approach based on Pathophysioloical mechanismsAnalysis of the disease

MechanismsNidana

Genetics, lifestyle, season, locality, occupation etc

Poorvaroopa & LakshanaSpecific to diseases

SamprapthiPathophysiological mechanisms

BedaStages

Patient ApproachSystematic Approach in Patient Examination & Evaluation

Evaluation of VayuPrana

◦ JeevanaUdana

◦BalaVyana

◦Dhatu Parinama & DhatugatiSamana

◦Aharapaka Apana

◦Nishkramana

Evaluation of AgniJatara

◦Aharapaka & MalanirmanamRanjaka

◦Raktha NirmanamDhatwagni

◦Dhatuparinama & Kleda Nirmanam

Evaluation of Dhatu SaraTwakRakthaMamsa & MedasAsthi Majja & SandhiSukra

Evaluation of MalaPureesha

◦Consistency Moothra

◦Colour etcSwedaOther mala

Evaluation of ManasSatwaRajaTamas

Type 2 Diabetes Mellitus

“A Vascular disease more than a true metabolic disease”

Macroangiopathy◦Stroke, CAD, Leg Gangrene

Microangiopathy◦Retinopathy, Nephropathy,

Neuropathy

EpidemologyDiabetic epidemic

Between 2003 and 2025, the number of patients worldwide with diabetes is going to increase 72% to an estimated 333 million people

Epidemological profiles and trends loaded against India

Predisposing FactorsGenetic predispositionObesityLifestyleLack of exerciseEnvironmentalInflammation

DIABETES – PATHOPHYSIOLOGICAL MECHANISMS

Beta Cell DysfunctionBlunting of the beta-cell response

with loss of first phase insulin secretion

With time, there is overall loss of insulin secretion

A decrease in beta-cell mass and death of these beta cells

Insulin Resistance

“Defect in ability of insulin to stimulate glucose transport into the cell”

ObesityFree Fatty AcidsInflammation

Alterations in Lipid MetabolismEctopic deposition of Lipids –

lipotoxicity◦Pancreas, Liver, muscle, heart

muscleInsulin ResistanceReduced TG synthesisEnhanced lipolysisIncrease in Free fatty Acids

InflammationLow grade tissue InflammationInflammatory markers raised in

obese personsInflammation to endothelial

dysfunctionResults in Insulin ResistanceProgression of Disease

◦Death of fat cells & Beta cells

Diabetes MellitusMultifactorial complex

mechanisms◦Pancreatic Dysfunction◦Insulin Resistance◦Altered Lipid Metabolism◦Inflammation

Chronic HyperglycemiaHyperglycaemic pseudohypoxiaOxidative stressActivation of the coagulation

cascadeInflammation

“Endothelial Dysfunction of arteries”

Diabetic AngiopathyMacroangiopathy

◦Myocardial Infarction◦Stroke◦Leg gangrene

Microangiopathy◦Retinopathy◦End Stage Renal Failure◦Peripheral Neuropathy

PRAMEHA

BeejadushtiSahaja PramehaBeeja Avayava DushtiInherited Agni Vaigunya

Kapha Krit Cha SarvamNavannaDadhiAnoopa MamsaAvyayamaAsuchitwamKapha Medo Moothra Vridhi

Physical & Mental Inertia

AGNI & PRAMEHA

Panchabuta AkashaVayuAgniApPrithvi

Agnishomeeyam – Evolution of LifeLife – Dynamics

Of BhutasJala

◦ Dhatusara, OjasAgni

◦ Jatara, DhatwagniVayu

◦ Panchavayu

Vayu

JalaAgni

Panchabuta & PramehaJalarogaJala Buta

Prasada – MalaA disease of Jaladushti progressing

to Dhatukshaya

Agni & PramehaJataragni – Ahara Parinamam

◦Ahara to Rasa ◦Khara Mala - Pureesha

Dhatwagni – Dhatu Parinamam◦Annarasa to Dhatu Sara & Ojas ◦Drava Mala - Kleda – Moothra

Agni & PramehaAgnidourbalyamAma formationSrotorodhaMedovridhiDhatwagnivaikalyaMedodushtiExcess KledaExcess Moothra formationDisintegration of DhatusMadhumeha

Agnidourbalya & Ama – Beta cell Dysfunction & Insulin ResistanceAtyaharaAdhibojanaLack of proper exerciseAgnimandyamFormation of AmaMadhura Anna RasaSrotorodha

Medovridhi - SthoulyamIncrease in Medas

◦Deposition of medas in abdomen,thighs

Dhatwagni VaikalyaFurthur increase in formation of

MedasSrotorodhaDhatwagni Dourbalya

Medodushti - PrediabeticDhatwagnidourbalyaVridha Medas – Dushta MedasSthira Dhatu Sara – Shithila

DhatuDhatu Parinama VaikalyaProne to CAD, CVA

Prameha – Vasthi RogaActivation of PithaDissolution of MedasFormation of excess Kleda Elimination of excess Kleda As

MoothraExcess formation of Moothra

‘Athimoothratha’

Prameha – MadhumehaActivation Of Vyana & Apana

VayuWeakened Agni & Disintegration

Of Dhatu SaraDhatu & Ojas converted to KledaAvila Moothra - Increased

concentration of Urine‘Madhumeha – Asadhya’

CLINICAL SCENARIO

Agnimandya & Ama StageBeta cell stimulation & reducing

Insulin resistance Agnibalavardhana & Amahara

◦Panchakolam◦Indukantham

Eating Habit ModificationLife Style Modification

Medoroga & Medodushti

Medohara & Atisthoulya ChikitsaDhatwagni Deepana

◦ Varadi Kashayam, Ayaskriti, Lodhrasavam◦ Loha Prayoga

Navayasam

◦ Mushta, Darvi, Thriphala, Devadaru◦ Vidangadi◦ Abyanga

Prabanjanam

◦ Udwarthanam Nalpamara, Eladi, Nisa

◦ Vyayama◦ Ahara Vihara

Prameha - AtimehanaPitha SamanaKleda VishoshanaMoothra SthambanaMedo Doshahara & Agni DeepanaTiktha Rasa & Seetha Veerya

◦Ekanayakam◦Thettamparal◦Niroori◦Vanga & Abraka

Moothra SthambanaKashaya

Nisakathakadi, KathakakhadiradiGulika

Nirooryadi, Swethagunjadi, Mehasamhari

Choornam◦Amritadi

Paneeya◦Ekanayaka Shadangam

‘Combine Medohara & Deepana Chikitsa’◦Chitrkathriphaladi, Navayasam

Madhumeha - AvilamoothrathaAggressive Treatment Prevent progression to Vatha stagePitha Vatha samanam & intensive

SthambanaMedodoshahara &

MoothravisodhanaBalyam & RasayanamAgnideepanamVathasamanam

AvilamoothramSilajathu Prayogam

◦RasayanamNisa & Amalaka in all stages

◦Nisa – Kledahara◦Amalaka – Rasayanam

Aveerabeejam◦Moothravisodhanam

Oushadham◦Akulyabdadi, Aakuyadi Gritam

Prameha - AvilamoothramIntensive Sthambana ChikitsaDhara

◦Takradhara◦Special Dhara – 28 days

SirolepamMoordha Thailam

◦Nisoseeradi, ArukaladiAbyangam

◦Lakshadi KuzhambuPizhichil

Krisha Meham Vata Pitha DoshaAgni VaishamyamStressSigns

◦Excess thirst & tiredness◦Karshyam

Sudden Progression to neuropathyVatha Pitha SamanamAgnideepanamMehahara & Balya

Krisha Meham - ChikitsaOushadham

◦Indukantham, Nisakathakadi◦Nirooryadi◦Amritadi◦Abrakam

Dhara & SirolepaPizhichilRasayanam

◦Amritha, Amalaka

PRAMEHA – COMPLICATIONS & ASSOCIATED SYMPTOMS

Prameha – Complications in Skeletomuscular System Microangiopathy & tissue

ischemiaChronic Inflammation Excess Kleda & SodhaDathushosha & Disintegration of

Structures

Approach – Management of Complications Aggressive Management of PramehaPrevent progressionEffective Management of ComplicationsKledahara & Sodha Hara

◦Kathakakadiradi with SilajathuVatha Samana

◦Rasnathamalakyadi, MaharasnadiBalyam

◦Bala, Amritha

“Treat Prameha effectively & complications will disappear”

Frozen Shoulder ACKledahara & Sodhahara

◦Kathakakadiradi with ChandrapraVatha Samanam

◦Maharasnadi with Trayodasangaguggulu

Snehana◦Parinathakeree, Panchasneham

Balyam◦Ksheerabala Prayogam◦Navara

Foot Abnormalities – Charcot footNeuropathic ArhtropathyManage PramehamVatha Samanam

◦Maharasnadi, GugguluBalyam

◦Navara

Vascular NeuropathyPeripheral – DSPMicroangiopathy & Nerve

IschemiaNerve Damage – Arhtopathy

◦Pain, Numbness, muscle atrophyAutonomic

◦Urination problems◦Erectile Dysfunction

Managemant - Vascular neuropathyAggressive Management of Prameha –

Vatha Pitha Meha◦ Nisakathakadi, Nirooryadi, Nisa & Amalaka◦ Amritadi

Dhara & SirolepaVatahara

◦ Rasnathamalakyadi, Ashtavargam,Balya & Rasayanam

◦ Bala – Ksheerabala◦ Amrita – Ksheeraguloochi◦ Abyangam & Pizhichil◦ Vasthi

Vascular neuropathyAutonomic – ED Vata Pitha Meha Samana

◦Nisakathakadi, AmrithadiVrishya

◦Silajathu, Abrakam, Vangam◦Jeevaneeyaganam◦Pizhichil◦Vasthi

Nephropathy - MadhimehamMadhumeha Chikitsa

◦Akulyabdadi Kashayam◦Silajathu

Rasayana – Saramabu Bavitha Silajathu

◦LajjaluSopha & Udara Chikitsa

PAD & PramehaChronic Leg Pain

◦Macroangiopathy – Atherosclerosis of Tibial artery

◦Guggulutikthakam◦Rasasindooram◦Amrita & Guggulu◦Mahamanjishtadi◦Madhusnuhi

PADLeg Gangrene

◦Guggulutikhakam◦Rasasindooram◦Mahamanjishtadi◦Amrita & Guggulu◦Madhusnuhi

Hyperglycemia as symptom

Stroke◦Ama◦Amahara Chikitsa◦Shaddharanam yogam

SummaryPrameha involves complicated

mechanisms which appear contradictory – Agnimandya, Ama, Medodushti, Dhatu Shaithilya & Ojakshaya.

Management requires understanding of different patho-physiology and treatment options should be adopted accordingly

THANK YOU