|Year : 2013 | Volume
| Issue : 1 | Page : 41-49
A brief review of researches on rheumatoid arthritis in Ayurveda
Department of Basic Research, AVP Research Foundation, Ramanathapuram, Coimbatore, Tamil Nadu, India
|Date of Web Publication||23-May-2013|
AVP Research Foundation, 136-137, Trichy Road, Ramanathapuram P. O., Coimbatore - 641 045, Tamil Nadu
Source of Support: None, Conflict of Interest: None
| Abstract|| |
To review the evidence on efficacy of Ayurvedic treatment taken either orally, topically, per rectum, or all routes in the management of Rheumatoid Arthritis (RA) based on published scientific literature. Systematic search of the online bibliographic database known as Digital Helpline for Ayurveda Research Articles (DHARA) was conducted to collect the data for all studies related to RA. The search has included the data from December 1945 to June 2012. A summarized and classified overview of prior research on RA in Ayurveda was generated from the collected data of published articles. Three hundred twenty five citations met our keyword search criteria. Out of these, only 127 citations were found directly relevant to RA. The trend of published articles in RA has shown that original research papers (70%) outnumbered review papers (20%) and only few surveys and position papers (2%) were found. Amongst the original research papers, 56% were clinical studies followed by 41% of preclinical studies. Most of the clinical studies were observational in nature (39%) and the rest were randomized uncontrolled trials (33%), or controlled trials (15%), and case studies (7%). It was found that clinical studies were predominant but of poor quality in terms of rigor and research design. Especially, research studies that addressed the holistic principles of Ayurveda were almost absent. However, Ayurvedic formulations were studied more than medicinal plants and external therapies.
Keywords: Amavata , Ayurveda, database, digital helpline for Ayurveda research articles, extracts, rheumatoid arthritis, siddha, unani, vatarakta
|How to cite this article:|
Mahapatra A. A brief review of researches on rheumatoid arthritis in Ayurveda. ASL Muscuskel Dis 2013;1:41-9
| Introduction|| |
Rheumatoid arthritis (RA) is a health condition that causes pain, swelling, stiffness, and loss of function in the joints. Medicines are available in conventional medicine for treatment of RA; however, some people also resort to alternative medicine or therapies.  People with RA may continue to have symptoms despite the use of conventional treatments, or they may have difficulties with side effects of available treatments. Patients may combine conventional treatment with medicines from systems like Ayurveda or herbal products that can be taken orally, topically, per rectum, or in combination for the management of RA to achieve better outcomes.
Ayurveda is one of the oldest and meticulously codified systems of healthcare in the world. However, in modern times, the Ayurvedic community has lagged behind in the task of projecting Ayurveda as evidence-based system with adequate research support to vouchsafe its therapeutic claims of safety and efficacy.
In the present context, there is not enough published scientific evidence to firmly establish that these systems of medicines or therapies are safe and effective for management of RA. There is limited access to published researches in the field of Indian system of medicines. An attempt has, therefore, been made to understand the usage of medicines from Ayurveda and medicinal plants that have been studied for management of RA through bibliographic search.
| Materials and Methods|| |
Keyword searching was done to locate articles reporting treatment outcomes in RA by searching published and available abstracts on Ayurveda and medicinal plants in Digital Helpline for Ayurveda Research Articles (DHARA) database. DHARA is accessible online at www.dharaonline.org. It is the first comprehensive online indexing service exclusively for research articles published in the field of Ayurveda and allied Indian System Medicine. 
The following keywords were used: Combination of "Rheumatoid Arthritis" or "Rheumatic" or "Rheumatology" or "Arthritis" or "Sandhivata" or "Amavata" or "Vatarakta" and also probable variations of its spellings. One hundered and twenty seven articles directly related to RA, Amavata, and vatarakta were selected from the 325 that met the search criteria and were included for further analysis.
Inclusion and exclusion criteria
The applied inclusion criteria are shown below in a flow chart [Figure 1]. 0.6% articles were found in DHARA database with search terms after applying inclusion criteria.
The applied exclusion criteria are shown below in a flow chart [Figure 2].
One hundred and twenty seven (127) out of 325 selected articles (39%) of the search results were directly related to RA in DHARA database after applying exclusion criteria.
The research papers were screened and classified based on the nature of submission, the nature of research, quality of research, study design, disease conditions, formulations, interventions, and the plant species used.
| Results|| |
One hundred and twenty seven abstracts were selected for further analysis after meticulous review. These were further classified into type of submission, research type, and research sub type. The type of submissions found in selected RA abstracts is shown in [Table 1] [Figure 3].
Original research papers (70%) were more in number compared to review papers (20%) and only few surveys and position papers (2%) were found.
The type of article found in selected RA abstracts is shown in [Table 2].
Clinical, pre-clinical, literary, and analytical studies, survey as well as systematic reviews were retrieved and are listed in [Figure 4] in descending order.
The research sub types in pre-clinical study of RA abstracts are shown in [Table 3] [Figure 5].
|Figure 5: Classification of RA abstracts on preclinical research-sub type|
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|Table 3: Classification of RA abstracts on preclinical research-sub type|
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in vivo studies (39%) were more in number compared to in vitro studies (34%) and only few in vivo and vitro combined studies (14%) and analytical studies (12%) were found in preclinical study.
The research sub types in clinical study are shown in [Table 4] [Figure 6].
Observational study (35%), randomized uncontrolled trial (35%), randomized controlled trial (13%), case report (8%), and systematic review (6%) papers were retrieved from the clinical studies.
In clinical research-observational and uncontrolled studies outnumbered randomized controlled trials and there were a few case studies. Out of 127 articles screened, only three dealt with systematic analysis. Out of these, two dealt with Ayurvedic medicine directly , and the other discussed about Ayurveda in the broader area of complementary medicine. 
Randomized controlled trial on RA
A systematic review on randomized trials by Edzard Ernst concluded on the paucity of randomized controlled trials (RCTs) of Ayurvedic medicines and existing RCTs failure to show effective therapeutic options for RA.  This systematic review was based on available seven studies, which fit the criteria of RCTs on Ayurvedic medicine in the year 2005. Only three of these studies were placebo-controlled RCTs. There were none that studied classical Ayurvedic treatment for RA nor any that allowed individualization of therapy. In the only methodologically high-quality trial  (based on a Jadad score  of 5) from this group, except for a significant increase in hemoglobin and a decrease in RF (P < 0.01) in the experimental group, the active treatment was not significantly superior to placebo. The second study, that indicated potentially beneficial effects of an Ayurvedic preparation compared to placebo, was not reported completely. 
The third trial's incompletely reported results showed no difference between the active treatment and placebo. 
The same author has published four papers reviewing previous studies on Ayurvedic interventions, complementary and alternative medicine (CAM) treatments, and herbal medicines in RA. In 2011, one more systematic review published on evidence for the efficacy of complementary and alternative medicines in the management of RA concluded that the major limitation in reviewing the evidence for CAMs is the paucity of RCTs in the area. The authors point out that available evidence does not support current use of CAM therapies in the management of RA.  Pointing out that a US survey indicated that 90% of patients with arthritic complaints seek CAM treatment, Ernst has published another review article on surveying the herbal medicines commonly used for four common rheumatic conditions: Back pain, fibromyalgia, osteoarthritis, and rheumatoid arthritis.  In September 2012, another systematic review was published on evidence for the effectiveness of practitioner-based complementary and alternative therapies in the management of rheumatic diseases: Rheumatoid arthritis. It was based on eleven eligible trials (Jadad scoring system) covering seven therapies (acupuncture, meditation, autogenic training, healing therapy, progressive muscle relaxation, static magnets, and tai chi) and concluded that none of the practitioner-based complementary therapies considered here is backed up by good evidence of efficacy or effectiveness in the management of RA. 
By the end of 2012, the number of published randomized (both controlled and uncontrolled) trials evaluating Ayurvedic treatment for rheumatoid arthritis has increased from seven in 2005 to 25.
Among these 25 studies, only seven were RCTs that evaluated the efficacy of Ayurvedic treatments in RA. The duration varied from 1 month to 9 months and was either two or three arm studies. The efficacy was tested with group of Ayurvedic medicines in comparison with control or placebo group. Six out of seven trials were placebo-controlled RCTs. Two out of seven RCTs did not show measurable efficacy, while the remaining trials reported improvement in clinical, functional and hematological parameters. Three of the studies met the American College of Rheumatology (ACR)/European League of Associations for. Rheumatology (EULAR) Criteria of improvement for rheumatoid arthritis. ,, The list of RCTs is shown in [Table 5].
There was a first of its kind attempt to develop and use placebos of the traditional dosage forms of Ayurvedic pharmacological medicine in a double blind, placebo-controlled trial.  The study compared safety and efficacy of standard allopathic treatment and multi-modal Ayurvedic treatment for rheumatoid arthritis in 45 patients. Patients were assigned to three arms that received allopathic treatment, Ayurvedic treatment or a combination of both. The study revealed that Ayurvedic treatment was approximately equivalent to methotrexate with fewer side effects. The patients showed clinically significant improvement on the Disease Activity Scores. Edzard Ernst recommended this study as blue print for future studies on CAM.  This Indo-US collaborative study conducted by Arya Vaidya Pharmacy, Coimbatore and the University of California, funded by the National Institutes of Health (NIH), USA has won the Integrative Medicine Research Excellence Award from the European Society of Integrative Medicine. 
In a unique study of classical Ayurvedic treatment (evaluating Ayurveda as a whole system intervention) for RA in the 1960s (published in 2012), allopathic physicians enrolled a total of 290 patients and Ayurvedic physicians administered individualized treatment, closely adhering to principles set forth in classical Ayurvedic texts. The duration of treatment varied from 1 to 6 months and results showed statistically significant improvement in all parameters from admission to discharge. The results indicated that classical Ayurvedic treatment was effective in this first cohort of patients who completed treatment. Although there was no control group, the results were positive enough to warrant further study of classical Ayurvedic treatment for RA as controlled trials. 
Case reports on RA
Case reports on RA in Ayurveda were found to be scare and only four papers could be listed. In one of the case reports, the author reports the contributing effect of Ayurvedic drugs prescribed for seropositive progressive RA on non malignant distal esophageal nodule.  Another case report studies rheumatoid arthritis as vatarakta, which when treated as per the classical line of management of vatarakta, also led to healing of chronic venous ulcer. 
Type of interventions in RA
Drug intervention studies were more in number compared to drug and therapy combination study and only two papers were on non-drug interventions.
The type of treatments found on RA is shown in [Table 6] [Figure 7].
Formulations used for RA
Forty-three Ayurvedic formulations were used either in oral or topical form used for RA. Thirty-seven types of Plant used either alone or in combination form or in the form of extracts in RA. The maximums used medicinal plants are Zingiber officinale, Curcuma longa, Semecarpus anacardium, Tinospora cordifolia, Boswellia serrata, etc. There were two drugs from animal origin, i.e., Coccus lacca and cow's urine and two drugs from mineral source, i.e., Rock salt and Zinc were used.
A comparative antioxidant study of Maharasnadhi Quathar and Weldehi choornaya has showed high antioxidant potentials in Maharasnadhi Quathar.  A study was to investigate the therapeutic potential of two gold preparations (Ayurvedic Swarna Bhasma and Unani Kushta Tila Kalan) in an Animal model. 
The list of formulations used in RA is shown in [Table 7]. The list of sources used in RA is shown in [Table 8].
Non-drug therapies used in RA
Two non drug therapies were reported; wearing of Coral beads-Astromedicine had remarkable effect on RA  and therapeutic potential of Satvavajaya therapy in the management of Amavata. In Ayurveda, Amavata is characterized by its eternal course, uncertain progression, and unpredictable series of exacerbations and remissions. Satvavajaya therapy of Ayurveda may be considered as a kind of patient education in rheumatology but with much broader base and much better applicability. 
| Conclusion|| |
The trend of published articles in RA has shown that original research papers (70%) outnumbered review papers (20%) and surveys and position papers (2%) were negligible. In the category of original research, clinical research (56%) papers had an edge over preclinical studies (41%). Most of the clinical studies were observational in nature (39%) and the rest were randomized uncontrolled (33%), controlled trials (15%), and case studies (7%). Clinical trials were more on Classical Ayurvedic formulations (42) and medicinal plants (37) and rest were external therapies (10), proprietary medicines (3), non-drug therapies (2) and whole system intervention (2). It could be concluded that, with respect to research publications on rheumatoid arthritis, clinical studies were comparatively reported more often but poor research design and lack of attention to holistic principles of Ayurveda become evident as major shortcomings.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]