Blood sugar and the treatment of Prameha

P.K.V.Anand

Vaidyaratnam Ayurveda College

Prameha for an Ayurvedic physician is a disorder of Medodhathu, which involves its entire channel including its roots i.e., Vrikka and Vapavahana. The diagnosis in Ayurveda for Prameha, as for any other disease, is by its symptoms. These symptoms are the presence of urine with Prabhoothathwa and Avilathwa at any point of the cource of illness. Diabetes mellitus also can be diagnosed as Prameha, as it presents the cardinal symptoms in urine, either in Poorvaroopa or Roopa stage or continue to present in its Upadrava stage.

The onset of DM is not demarcated and is often found suddenly during a casual check up. Presence of hyperglycemia, even without the presence of the two cardinal features, makes us convenient to consider those patients as potential candidates for Prameha, or actual cases with a differed manifestation of cardinal symptoms. Hyperglycemics, those who have a possibility of crossing the renal threshold of glucose in the future, need not be considered as Pramehi at that moment in a real sense. Instead has the highest predisposition to be a Pramehi. All such laboratory evidences which were not discussed by the seers, is yet to be discussed among the community and accepted into Ayurvedic methodology of diagnosis.

Sweetness in urine is a universal Poorvaroopa for all twenty types. Those who had turbid and excess urination at any point earlier can also be labeled as Pramehi for, it never leaves its job (Prameho Anushangeenam Sreshtam). To make the diagnosis specific, we may also differentiate the stage of prodroms, stage of manifestations and the stage of complications. As far as Prameha is concerned, the Roopa is differented by the presence of Prodroms along with a mild increase in the quantity of urine. Neither of them is easily noticeable by the patient or vaidya. Poorvaroopas of Prameha is expected to continue to exist throughout the disease. Interestingly, the exception which makes this disease distinct is that the presence of all poorvaroopas simultaneously does not offer a clue to its prognosis.

The dosha-dooshya distribution of any clinical condition is identified by the nature and severity of symptoms. In Prameha all such urinary symptoms are subjective. They are physical properties with high individual variability of perception and cumbersome method of inspection. Besides the patients are not aware to observe and report such changes. This makes it an impossible task for today’s Vaidya to follow. So for all practical reasons, dependency on blood glucose estimation in DM form of Prameha is justifiable.

Awareness of blood sugar levels as major monitoring criteria of DM, has presented glucose as the major fear factor and culprit to be fought with. Glucose, on the contrary is the major energy exchange currency in the body.  The focus should move on to the exchange rate and not on the exchange meterial inorder to keep a diabetic healthy

The symptoms of DM and the sugar in blood

Circulation of Rasa and Raktha is jointly all over the body. Hence the blood sugar value represents the collective sweetness of Rasa & Raktha. Major part of sweetness might be contributed either by Rasa or by Raktha, which is not separable. This sugar level of Rasa-Raktha complex, in healthy individuals, is kept steadily in the minimum range of 60-100mg /dl, and derives mainly from the digesting food. When food is not available for digestion, this level is maintained by inflow from the storage of bodily tissues.  In other words, the sugar level is prevented from getting lowered, by breaking down bodily tissues, which is obviously a Vatha-Pitha style of activity. After the intake of food, till the completion its digestion, the availability of sugar from food, prevents hypoglycemia. The presence of food in the GIT, through kapha dominant series of activities, supplies sugar to the Rasa-Raktha complex. The sugar gets utilized and the level gets reduced by Vatha-Pitha dominant activities like exercise, thinking, etc. Direct utilization of glucose is highest in the brain. This reflects whenever there is a higher activity rate in the brain, like anxiety or a stressful situation, which are Vatha-Pitha dominant, more and more glucose is made available in the Rasa-Raktha complex either from food or from the tissues, to meet the increased need. This happens in similar Vatha-Pitha dominant hours also. For example, an increased value of blood glucose in fasting blood sugar investigation, points to a Vatha-Pitha dominant status of Prameha. A temporary abnormal hike in the blood sugar value is often observed in many individuals after a RTA or other stressful situations, owing to the mental & physical stress of that situation, which is again a Vatha-Pitha dominant situation.

Polyurea, Polydipsia and Poliphagia are the physical manifestations of DM.  Among them first one is the symptom, second is a complication and the third is something that is not at all listed as a part of Prameha. Many vaidyas prefer to accept polyphagia as a part of Prameha, by its close connection with Sthoulya & Medoroga, which have polyphagia as their symptom. Polydipsia does not fit into the definition which says, complications are those which appear after the onset. Being a diagnostic feature at the onset of the disease itself, many vaidyas does not consider it as a complication.  For them excess thirst and hunger are due to Vidaha existing in the body, a sign of Pitha domination.

Analysis from another angle reiterates that, this hunger points to Athisthoulya and Athyagni. Dusti of Medodhathu is common to Prameha, Sthoulya and Medoroga. Annarasa, vitiated by Ama & Sleshma, and rich in madhurarasa is a dominant constituent of the Rasa-Rakthadhathu in these three diseases. This annarasa which is sweet, itself is the asthayirasadhathu.  The blood glucose estimation  measures the over all sweetness in the form of glucose, from a mixture of   above mentioned sweet asthayirasa, sthayirasadhathu, asthayi rakthadhatu, Sthayirakthadhatu, Laseeka, all other Aapya constituents, precuser representations of all other Dhatus as per Khalekapothanyaya, Kleda which are to be converted into urine & sweat, other Dhathumalas.  

Annarasa and the Rasadhathu generally remain sweet in them. It is not possible to differentiate the source of glucose from such a complex admixture called blood. The blood glucose originates not only from Aamasaya but also from the glycogen store of the liver. As long as food is available in the GIT and digestion is ongoing,  the source of glucose is obviously Rasa oriented. Similarly, when this Kapha-Pitha stage of digestion is finished and Pitha-Vatha stage begin, when no more glucose is availed from GIT, the glucose level is maintained by breaking down the glycogen store in the liver, which is the root and storage of Rakthavahisrothas. Thus input of Rasa oriented glucose into blood is active during Kaphakaala while Raktha oriented glucose enteres blood during Pitha-Vathakaala. The output of glucose in healthy is by its utelisation in tissues, which is increased by exercise, stress etc.

Diabetes mellitus is obviously not a disease of blood sugar level only. It involves each and every tissue in our body. Presence of Prameha makes every tissue in the body vulnerable to become Aapyadhathu. Proteins, fat etc., gets disintegrated to the level of glucose eventually. When this disintegration extends deeper to the structural levels, compactness of organs & structures becomes lost and Sladha sareera appears. When this breaking down of glucose at liver is active and over rules the breaking down from food source, the body becomes thinner and organs less functioning.

The seat of sweetness

Treatment is always in consideration to the Stani doshas. Very often Sthaani dosha dominates aaganthu dosha in the clinical presentations. In the context of DM, monitoring the disease status is by assessing blood and the result of treatments should reflect in blood. When managing the integrity of blood has the priority, rather than understanding glucose as Madhura and Kaphavardhana, our focus should be on keeping the Rasaraktha complex away from excess sweetness and Kapha dominance. Even when we refer Rasa as Apdhatu, Kaphasthana etc., texts hold that Rasadhathu is also a seat of Pitha. Raktha is a well known Pithasthana. Thus  the Kaphapithasthana – Rasa, and the Pithasthana – Raktha together contains  the madhura or glucose in this context, and serves as an index.

The affected Dooshya is Kapha and the kind of affection is loosing its original property of viscosity and aquiring fluidity. Unlike other two doshas, the Kopa of Kapha is caused by its opposite veerya i.e. Ushna. For example, the Kapha which gets accumulated in winter, by the similarity in properties of the season, turns into the stage of Kopa  by the presence of Ushnaveerya in Vasantha. Heat melts the dense and viscus Kapha into fluid state to trigger Kapha diseases in that season. In a similar sequence of events, Abundant Kapha which has lost its density and viscosity to become fluid by heat happens to be the Dooshya visesha in Prameha. The rate at which the structural integrity of tissues turns to fluidity, and gets one with both the Rasa-Raktha complex & dooshyas of Prameha, indicates the severity of Prameha. Glucose, as an important component of this dissolution is a practically useful index for clinicians.

Blood glucose level, can be useful for Ayurvedic system, despite the notions that any diabetic with no urine sugar is not a Pramehi at that moment, or it does not include all varities of Prameha etc. Normal range of blood sugar is identified and fixed based on the average sugar levels of apparently healthy individuals of the society. This is the average of a society which is getting increasingly exposed to the causes of lifestyle diseases including prameha. In other words, this is the arbitrary limits of blood sugar derived from the data of apparently healthy individuals including potential or future diabetics. Unlike English system of medicine, Ayurveda gives equal importance to both generalized information like social average and to distinguished information like individual’s peculiar contribution to his blood values. A Vaidya should not mistake his objective as merging the patient’s unique health status with the social average. Instead he should speak from the individual grounds of the patient’s health, for each case and educate him.  

Balancing the glucose level –

Glucose is the basic currency for energy exchange in the body. In general, to keep it’s rate of exchange within a range, there are three approaches.

1. Control incoming glucose from the GIT
2. Control incoming glucose from Lever
3. Exhaust the glucose load of Rasaraktha complex either by excercises or by insulin

Considering the roll of  pitha, both in the Asraya and Asrayi, there exists a situation where excess of Agni prevails. Hence in diabetics reducing the quantity of food will initiate flow of glucose from hepatic sources, ending up in Dhathukshayam. Altering the quality of food than its quantity makes a practical solution here. Specially processed Yava etc., as suggested for Kaphaja prameha are to be used here. Acarbose, Methika, Jamboo nuts, bittergaurd etc., are proven to reduce the entry of glucose molecules from GIT to Rasaraktha complex, there by reducing the glucose load. Many oligosaccharides, owing to longer duration needed for the digestion of such carbohydrates, will keep the post prandial rise of blood sugar in a lower level. Selecting food stuffs with lower glycemic index and adding medicines suitable while cooking to reduce this index will benefit in a lowered PPBS. It is to be noted that, the treatment of Kaphajaprameha described is such selection of food stuffs and preparing them in suitable Kwadhas.

The glucose input from hepatic sources can also be reduced by reducing the Vathapaithika situation by reducing vidaaha and ushnaguna. This is how Sthambhana chikitsa becomes the line of treatment in prameha. Take the example of Thakradhara which is sthambhana & effective in reducing bloodsugar. Even when exercises and brain works helps to exhaust the glucose load, they also increase both the need and availability of glucose in blood. Hence the beneficial results of excercises are obtained when the quality of food is altered and adopt Vasantha and greeshma charya which in turn reduces Vidaha.

The first Agryoushadha of Prameha is amla, which is generally a Thridoshahara drug and specifically Pithasamana. Second one is turmeric which is the choice of drug in skin diseases seated in Rasa & Raktha for want of Rakthasudhi. These two are good examples which say the treatments should focus on the seat of DM such as RasaRaktha complex, Kapha which is Vyanjaka and the Pitha which is Utpadaka. The relevance of  Guloochyadi Kashaya as a model drug for Prameha, is also with the same reasons. It is indicated in Pithasleshmajwara, which can be interpreted here as the increase of glucose from GIT source. Using a medicine indicated in the context of Jwara, for another disease is accepted whenever a suitability and similarity of sequence of events (in here Vidaha) exists. Prameham is a disease where excess utklesa results in the production of excess kleda.  There is a similarity with the utklesa happening in vomiting, where both are dependent on Annarasa, Rasa, Amasaya, etc., thus making this medicine suitable for both. The dosha which offers substance for the disease to become Vyanjaka factor is Kapha. The instigating factor which melts & adds dravaguna to kapha is Pitha, which shows its presence by vidaha, increased heat, causing polydipsia, which is another indication of this drug. Interestingly, Kaikulangara Ramavarier, in his Bhavaprakasa commentary of Ashtangahridaya, has quoted the original text as Agnihrit instead of Agnikrit in its indication. Adding to its suitability to the condition, his commentary indicates Guloochyadi kashaya in Atyagni, where polyphagia becomes its symptom, as for DM. The data from Vaidyaratnam Ayurveda Foundation, which is given below shows the effectiveness of this drug to reduce blood sugar in usual doses.

 

Prameha, despite the fact that it is seated in an important basic structural component like Medas,  this article discusses only about blood glucose, which is the accepted index for monitoring. Keeping the glucose level within limits is an important concern for any diabetic. Even then it does not become a complete treatment, which can attend the multifaceted and fatal degenerative and changes due to the illness. The presence of excess sweetness in blood can be viewed also as a response to the instigating Pitha and the degenerative Vathapaithika trend of events. Ayurvedic scripts did not find sugar as a major apathya in Prameha as evidenced by the presence of sugar in chandraprabha, Agasthyarasayana, Sathavareegula etc. It is well known that most of the medicines indicated in Prameha, does not offer a satisfactory and consistant blood sugar reduction. This surprising uncertainity is due to their limited range of action defined by the status of Doshas, and dependency on Agni to transfer drug effects all over the body. 

When treatment is for sweetness

Treatment, at least in principle, changes according to conditions. For each patient, condition differs, making the treatment different for each patient at each moment. Selecting a particular medicine in a defined condition of the disease, instead of using it randomly anywhere in the disease, makes that drug successful and can pass through a RCT. Each disease condition is not defined, identified or named by the Ayurvedic community at present. This makes it difficult for the same individual Vaidya to offer euglycemia, in another person, with the same medicine which he found successful in many others. The drug which was successful to keep glucose under control until yesterday turns useless by a turn of his bodily conditions. If only such random results are made available, this uncertainty of Ayurveda will continue to exist until a cause and effect relation is found out. Should we have a positive step in this regard, the blood sugar fluctuations, non response to treatment etc., are to be connected with its causes.  Differentiating prediabetic stage as Kaphaprameha, diabetic stage as Pithaprameha and Diabetis with complications as Vathaprameha is clinically beneficial and becomes a priliminary guide line for it.

Vaidya who bypasses this contemplation on clinical condition along with their  patients who fail to report details, find a way out in English medicines, single drug remedies or in rasoushadhas which act independent of dosha status and agni.  Their hypoglycemic effect is the only reason for their demand in the treatment of Prameha. If the objective of treatment is the same hypoglycemic effect, Vaidya should select the best hypoglycemic agent even if it is from another system of medicine for ample data regarding its actions are already available, and make precision in treatment.

The use of insulin is also justifiable for Ayurvedic system, either as supplementing a constituent of a Dhathu or as administration of a Jangamoushadha. For those who might argue that such a method of administration is not mentioned in scripts, can refer to the description of Pranalini naadiyanthra, which was used to administer medicines directly into blood, as quoted from Vridhakaasyapa in Kriyakoumudi by Sri V.M.Kuttikrishnamenon. Soochikabharanarasa has another similar method of administration.

There are Vaidyas who hold the argument that only those available in an age old script deserves to be performed as Ayurvedic treatment. I am sure that they will not be diagnosing and treating Diabetes Mellitus based on blood sugar values, instead on urinary symptoms, hence this article might not be beneficial to them. Still, if we limit the soul objective of treating a Pramehi is to keep blood sugar in normal range, this independent medical system named Ayurveda, will very soon shrink as a herbal alternative to Allopathic system.