Role of Argwadha Nitya Virechana in Madhumeha (Diabetes Mellitus-II): A Case Study

Diabetes Mellitus is now considered a pandemic. Especially in India, the number of patients increased at 14% prediabetic, becoming the capital of Diabetes. It is a clinical syndrome which is characterize by an increased level of blood sugar. In Ayurveda, the ṁadhumeha is explained as a type of prameha. The kinds of madhumeha is of two. One is dhatukshaya, and other is avaranjanya. The avaranjanya type of Madhumeha is allowed to be treated with the shodhana process. In which vamana and virechana are effective. Objective: The objective of this study was to study the efficacy of Nitya Virechana in the management of madhumeha. Case report: A single case study of a 59 yrs old male patient who was already diagnosed with madhumeha before 21 days. Symptoms such as pippasa, shramdaurbalya, Bahumutrata were present; after investigation, he was advised for Nitya Virechana. Result: Symptomatic assessment of the patient was carried out after treatment i.e. after Nitya Virechana and outcome was satisfactory, and the quality of life of patient was significantly improved. Conclusion: Nitya Virechana brought about good relief in symptoms in patients with Madhumeha and controlling the blood sugar level. Case Report Deshpande et al.; JPRI, 33(33B): 170-176, 2021; Article no.JPRI.70546 171


INTRODUCTION
Diabetes is the current global problem that affects the economic, physical and mental health of society. The prevalence of Diabetes in 2014 was 382 million, and it will be 592 million in 2035 by the International Diabetes Federation [1]. Diabetes Mellitus (DM II) is a metabolic disease in which the endocrine system has genetic susceptibility and the insulin-regulating tissue. It is caused due to environmental and dietetic factors resulting in insulin resistance and impaired Beta-cell functions [2]. Especially in India, the relationship between calorie intake and obesity increases rapidly due to high fat diet reduction in energy expenditure and urbanization. Due to excess stress and the lack of exercise is the main reason for obesity and Diabetes [3].
Changes in fat and protein metabolism are involved in Diabetes mellitus. Consequent changes in fat and protein metabolism lead to glucose metabolism impairment. Insulin is responsible for not only glucose metabolism but also fat metabolism. Insulin impairment leads to changes in fat, and glucose metabolism leads to Diabetes. Constant high glucose level changes gradually deteriorate insulin secretion [4].
In Ayurveda the Madhumeha is the subtype of vatik Prameha. It has two types one is avarnajanya and other is Dhatukshayajanya. According to Sushruta the vyan Vayu and apanvayu are play the significant role in the prameha pathogenesis. The vyana vayu is essential to the movement of every particle of the body and apana vayu for the excretion when the watery content that is kleda increased it goes into the bladder and increased the urine frequency and the quantity [5].
The treatment of Madhumeha is sanshodhana in which Vamana and Virechana explained in the Samhita. The doshas excess in the madhumeha, so the Shodhan is expressed in the patient of sthulpramehi means the obese patient and santarpan in the lean patient [6]. Many virechaka drugs are explained in the samhitas like the Snuhi. This is the solid purgative. Argwdaha is choosen here for nitya virechana, which is explained in the Prameha. For this purpose patient daily gets the virechak kwatha, which the patients get 2-3vegas is allowed. In Chakrdatta, the Chaturangulakwatha is described in the treatment of prameha [7].

Medication
history-patient on the anti hypertension medicine-Tab. Salmo 13.5 mg from 2yr, Past history-Lichen planus patient took steroids before 5 yr.
Family history-father, had a history of Diabetes. On this complaint the general examination did.

Mutravaha-excess urination, night urination.
Hetu-In this patient, excess eating of sweet, jaggery, curd, nonveg especially fish and milk and day sleeping are found.
Samprapti-Excess intake of Kapha, pittakar diet and routine raised the Mansa and meda levels in the body. This increased level of Kapha and meda obstructed the channels margavrodha. Avruttavayugati disturbed the oja, and vata increased. Vayusrukshaguna Madhur rasa of Ojas changed into the kashaya rasa. This ojas mixes with the mutravahasrotas, and prakupitvayu expels the Oja like Madhu. Avrittavata then entered the mutravahasrotas and down towards the bladder, and frequently, honey-like urine was seen, and Madhumeha occurred [8].
By above finding patient advised for blood sugar and other investigations. The levels of blood sugar reported rose. It is confirmed according to ICD criteria as a diabetes mellitus-II. According to Ayurveda it established as the Madhumeha.
On the above observation, advised for random blood sugar, it was 179 mg/dl. A detailed investigation suggested the patient. And confirmed diagnosis as Madhumeha. And the patient is fit for them. The consent was taken from the patient, and he agreed to Ayurvedic treatment. Then he advised Nitya Virechana (Daily purgation) with Argwadha kwatha. 6gm of fine powder 960ml water boiled 1/8 part and become 120 ml kwatha prepared as per Sharadha Samhita kantha description. This kwatha advised for 21 days. It's action like the, but the Vegas is less as compared to classic. The observation of Vegas is routine till day five afterword's patient get the 2 or 3 Vegas after taking the virechak kwatha. Samyakshuddhi lakshans found in 6 the day of nitya virechana specially laingiki shuddhi found. Samyaklakshnasnot found in vaigiki and maniki. Due to the Nitya virechana the quantity of the drug is less than the classical dose as per dose the Vega is less, but the laingikishuddhilikeshirolaghav, indriyashuddhi, udarlaghav observed.
The observation before and after treatment is as follows. The Argwadhakwatha shows the effective result in the investigation and on the subjective criteria.  Atinidraswedadhikya Shramshwasa, Vibandha. But no effect on pipasa. On this result, the Argwadhakwatha has the sansran property in which it removes the sticky doshas on the walls of the gut. By removing the lead and mala from the body, it becomes clean, and symptoms get relieved. The action of Argwadha kwatha is mild in action; it does not exhaust the body. The patient get 1-3 times lose bowel from 6days after taking kwatha, and after bowel, the patient advised the bland food. During this procedure, patient get complete evacuation of bowel and freshness and blood pressure, and other examinations are normal. Samayaksiddhi Lakshana observed. On the other side, Diabetes is caused due to the excess use of the dairy product and day sleep which is already explains in the samhita which is observed in the patient [9]. Kleda is the symptom found in Madhumeha, in which mala get accumulated in the kostha and night urination and frequency of urine occurred due to the doshyas in bladder [10]. Medvahasrotas is already disturbed, so the durabaly, pipasa, shrumshaws and kshudhadhikya, swedadhikya observed [11]. Argwadha kwatha nitya virechana removes the doshas and lowered the blood sugar level and symptoms [12],

Probable Mode of Action of Nitya Virechana
Nitya virechana is a concept and type of Virechana. It is mentioned for the treatment where bahudoshavastha condition [13,14,15] and madhumeha is a bahudosha disease. for the patient who has the vitiated doshas and is present in the koshthas. In Madhumeha the doshas are vitiated and present in koshthas. Nityavirechana can be the effective way to lowered the doshas quantity and breaking of pathophysiology. It is the treatment in which the body is cleaned through evacuating the watery content and pitta, mala, kappa, vata. In Madhumeha already the liquid content (kleda) is excess [16]. Administering Argwadha kwatha which is chosen for nityavirechana is responsible for removing doshas sedimented in koshtha. Madhumeha has the main symptom of vibandha; due to this, the mala accumulate in the koshtha, and 21 days nitya virechana removes the doshas in madhumeha. Abnormal meda dhatu is the founder of Madhumeha. Excessive kleda in Madhumeha observed and in karma removes the kleda means watery content from the body. It also acts on the vitiated Meda dhatu and as per Vaghbhata draw the vitiated doshas by nearest route [17]. The patient found relief in the symptoms.

Probable Mode of Action of Argwadha
Argwadha is the laxative drug that causes the doshas to stick on the walls of koshtha to get washed out. It has the mild in action it is not exhausted to the patient, and the property of Argwadha is adhobhaghar shodhan as per Samhita. In the Madhumeha, the doshas accumulated in the koshtha in the lower region, so it evacuated the doshas. As per modern the Argwadha is Antilipidic as well as the antidiabetic. In the patient of the above case, the patient shows the reduced blood sugar level and HbA1c and the lipid profile. By the virechaka property of Argwadha, the doshas wash out slowly, so the subjective criteria get the effective result. Few of the related studies were reviewed [18][19][20]

CONCLUSION
Madhumeha is occurrs due to the Dhatukshay or Margavrodha.
On the above patient, Margavrodha observed. Due to the kleda and Vibandha mala get accumulated in the channel and Madhumeha symptoms are seen. In Madhumeha, doshas collected in the lower part of the body and is the nearest route to remove this kleda and obstructed stick doshas through the bowel. Argwadhakwatha Nitya virechana is a promising treatment seen in the Diabetes. The patients elevated blood sugar level gets down to normal, and the hyperlipidemia becomes normal. The main effect on the HbA1c down towards the normal. The subjective criteria of Madhumeha get relieved by this procedure. Obstruction of the channel due to doshas get washed out through bowel, and the symptoms are relieved. At the same patient, get relief in subjective and investigative criteria. Further studies on the same conducted on more patients are necessary for more illumination on the Madhumeha.

CONSENT
It is not applicable.

ETHICAL APPROVAL
It is not applicable.

COMPETING INTERESTS
Authors have declared that no competing interests exist.