Study of Guduchi Kwath (Tinospora cordifolia) in patients Of Dengue Fever with Thrombocytopenia

Study of Guduchi Kwath (Tinospora cordifolia)  in patients Of Dengue Fever with Thrombocytopenia

Abstract

Keywords – Dengue fever,Vishamjwar, Platelet count, thrombocytopenia, Guduchi Kwath

Introduction

Dengue fever is an acute infectious disease caused bu an arbovirus in the Flavivirus genus & is transimitted mainly by bites of the Aedes aegypti and Aedes albopictus mosquito species.This disease can be correlated with Vishamjwar in Ayurved.

Aim

To study the effect of guduchi kwath in patients of dengue fever with thrombocytopenia

 Objectives

To study the clinical features ,laboratory profile in patients with dengue fever.

Material and Methods

Guduchi Kwath prepared as per Sharangdhar Samhita

180 patients with age > 18 years with Dengue NS1 positive or dengue IgM positive or IgG & IgM  positive with thrombocytopenia

Results

 100 % patients received Guduchi Kwath, whereas 16.66 % percentage of patients were purely on Guduchi Kwath while remaining 150 patients ,i.e. 83.33 % patients received Guduchi Kwath plus modern medicines as per need. Out of the 150 patients ,6 patients i.e.4% patients  were referred outside having severe hemorrhagic shock conditions for further management. All patients responded well.

Conclusion

            Guduchi Kwath in the dose of 40 ml mor-evening in the dengue fever showed improvement in the platelet count. All patients responded well.This can be used as a single drug in uncomplicated cases.

Introduction

            Dengue fever is an acute infectious disease caused bu an arbovirus in the Flavivirus genus & is transimitted mainly by bites of the Aedes aegypti and Aedes albopictus mosquito species. There are four serotypes (DEN-1, DEN-2, DEN-3 & DEN-4).

The disease manifestations ranges from a flu like illness known as dengue fever to a severe fatality known as dengue haemorrahagic fever and dengue shock syndrome.This disease can be correlated with Vishamjwar in Ayurved.

Objective

            Recently (June 2014-Oct. 2014) there was increased incidence of Dengue fever in urban as well as rural area.During the said period near about 190patients visited Bharati Ayurved Hospital. 180 patients (Age group -18-70 years)  which required admission in the hospital  were admitted whereas 10 patients were not admitted due to complicated medical conditions.Few of the patients referred from outside clinics having fever with thrombocytopenia and diagnosed dengue fever. 6 patients referred outside having Dengue shock syndrome after admissions .There is generalized misconception about use of Ayurvedic medicines in Dengue fever particularly thrombocytopenia and its outcome.Hence we decided to use Guduchi Kwath in few patients of Dengue fever with thrombocytopenia.

Materials and Methods

            A prospective study was conducted in our hospital in the IPD of Kayachikitsa department from June 2014-Oct.2014.Various symptoms and signs were found in the patients.High grade fever(ranging from 102^o F-104⁰F) with chills and break bone,headache, backake andache in the extremities accompanied by sore throat, prostration and malaise were found.

            Maximum patients had conjunctival suffusion (redness)and skin-flushed or blotched  with maculopapular rash sparing  palms & soles.After the rash fades ,localized clusters of petechiae (Petechial haemmoraghes ), on the extensor surface of the limbs and over chest and abdomen ,back were found. Few patients complained of itching all over the body in the beginning only and later showed thrombocytopenia.

            Few %  of patients found with signs of cardiac involvement.Showing cardiac suppression as bradycardia ,hypotension etc. Hepatitis with mild jaundice was found in few of the cases.Dengue hemorrhagic fever also found in children living in endemic areas.(Pune- Cases reported from urban as well as rural area in the Pune district.)

            Restlessness,epistaxis and abdominal pain –these symptoms were complained by the patients along with signs of hemorrhage –ecchymosis,gastrointestinal bleeding and epistaxis were also reported. Gasroenterologic complications –hemorrhage,tenderness & ascites were also found.Few of pts with secondary infection—dengue shock syndrome- acute fever,hemorrhagic manifestations & marked capillary leak- pleural effusion & ascitis – tendency for shock were treated very carefully with the help of experts in the field .

            Continuous abdominal pain with vomiting,bleeding ,a decrease ,in the level of consciousness,rash,conjunctival  congestion & hypothermia – dengue shock syndrome along with acute kidney injury in dengue shock syndrome were referred to ICU after consultation with the seniors.Complicated patients with pneumonia, bone marrow failure,hepatitis, iritis,retinal hemorrhages ,old age patients with bacterial superinfection ,higher fever ,gastrointestinal bleeding,kidney disease and altered consciousness were also referred to ICU from the casualty.

Laboratory  and Radiological Investigations

1) Thrombocytopenia, increased fibrinolysis and hemoconcentration – hemorrhagic form of disease

2) Haemogram with ESR .Leucopenia .ESR-normal

3) Detection of specific viral protein NS1 by ELISA } Platelet count < 100000/cmm

4) Dengue IgG,IgM in qualitative way} Platelet count < 100000/cmm

5) LFT deranged

6) Prothrombin Time

7) X-Ray Chest- in DHF-infiltrates &pleural effusions

8) USG –A-P – hepatitis, hepatomegalae,spleenomegalae,ascitis.

Treatment

Guduchi (Tinospora Cordiofolia)

Botanical Description –

Large,  glabrous, deciduous climbing shrub.

Stem   –   stem is covered by transperant layer that can be peeled off. Leaves   -  heart shaped 2-4 cm in diameter, individualized, pointed at tips and slimy, long petiolate.  

Flowers   - small yellow or green,  male flowers in clustered,  female flowers usually  solitary.       

Fruit -  drupes ovoid or subglobose, glossy red pea sized, appearing red on ripening.

Seeds – white,  bean shaped

Habitat   -   Found throughout tropical India, ascending to an altitude of 900 m from Kumaon eastwards as well as southwards upto Shri Lanka.

Properties -

Rasa             -     Titka,  Kashay

Virya            -     Ushna

Vipak           -     Madhur

Guna            -    Guru, Snigdha

Prabhav      -     Vishaghna

Karma   - 

Doshakarma   -  Tridoshashamak, Pittasarak

Other Karma     -  Kushthaghna, vedanasthapan, trushnanigrahan, dipan, pachan, anuloman, krimighna, hridya, rasayan, balya, vishaghna, vrushya, pramehaghna, mutrajanan, jwarahar, sangrahi

Chemical Composition –  Tinosporine, tinosporon, tinosporic acid, tinosporol, tinosporide, tinosporidine, columbin, chasmanthin, palmarin, berberine, geloin, giloinisin, 1,2 – substituted pyrrolidine, etc.

Pharmacological Actions –

Hypoglycemic, anti-inflammatory, antibacterial, antimicrobial, antipyretic, antiarthritic, antiallergic, hepatoprotective, analgesic, immunostimulant, antioxidant, hypotensive, adaptogenic, antitumor , antidiabetic, etc.

Use In Various Deseases – Gout, skin conditions, haemorrhoids, diabetes, fevers, rheumatoid  arthritis, eye diseases,  general debility, asthama, vomiting, flatulence, acid gastritis, fractures

Useful Parts – Stem, Leaves, Sattva, Root    

Pharmacognosy –

STEM – terete, sparcely lenticellate. Young stem green with smooth surfaces and swelling at nodes, older ones show a light brown surface marked with protuberances due to circular lenticels.

Dose  - stem powder – 3-6 gm, stem decoction – 50-100 ml, sattva – 1-2 gm

Substitutes And Adulterants – T. crispa ,  T. chinensis. are substituted or adulterated.  Guduchi sattva is adulterated with flour of potato, sweet potato, arrowroot, banana, etc.

Preparation Of Guduchi Kwath

            1 Pal (40 gm) of raw of Guduchi Kand (stem) taken and added with 16 times of water (640 ml ) ,boiled (on Mandagni) and reduced to 80 ml  (1/8^th part)  ,filtered and administered in the morning and evening.

Treatment

1) Isolation and beds with mosquito nets and mosquito repellent coils wherever necessary.

2) Tepid sponging

3) Guduchi Kwath 40 ml mor-eve after meals to every patient.(180 patients) . Out 0f 180 patients 30 patients were purely on Guduchi Kwath.They were given iv fluids wherever needed.These patients showed platelet counts in the range of 20000-100000/cmm and having no any other complications except mild ascitis and mild pleural effusion in few patients but still were stable. It is found that this Kwath helped in increasing the platelet counts .Also in lowering the temperature and also worked as analgesia.Improvement was seen in the appetite and also inrelieving maculopapular rash and itching .

4) Paracetamol than NSAID’s for analgesia and lowering temperature. Inj . Febrinil 2 cc iv as per need to lower down the temperature.

5) Volume support- RL and as per the need and monitoring vital signs and blood volume – complications of dengue hemorrhagic fever or shock syndrome

6) Blood products – RDP(Randomised donor platelets) ,SDP(Single donor platelets) , Fresh frozen plasma (FFP).Platelet transfusions for severe thrombocytopenia<10000/cmm or when there is evidence of bleeding

7) Corticosteroids- role not proven but it is in practice of giving short course of Inj .Dexamethasone in tapering dose. It is found to be very effective.It is given in the patients where platelet count showed downward trend and below < 50000 /cmm.

8)  Pressor agents

9) Antibiotics wherever needed to prevent second infections preferably Fluroquionolones

10) Antiemetics  and Antihistaminics whever needed.

Pathyapathya

Pathya - Manda, Peya,Vilepi,Siddha Dudgha, Phalarasa, Shadangodak,Siddha Jala

Vihar- Strict bed rest,no any kind of exertion or overexertion,toilets shoul be near to the bed or bed-pans advisable.

Apathya (Contraindicated) – During active and remission phase of fever till patient regains vigor and power,diet which is Vidahi ,Guru ,Virrudha and Asatyma in nature, sex indulgence, exercise ,exertion ,overeating ,bath and unnecessary exertion should be avoided.

Outcome

1) 100 % patients received Guduchi Kwath,whereas 16.66 % percentage of patients received were purely on Guduchi Kwath while remaining 150 patients ,i.e. 83.33 % patients received Guduchi Kwath plus modern medicines as per need. Out of the 150 patients ,6 patients i.e.4% patients  were referred outside having severe haemorrahagic shock conditionsfor further management.

2) All patients responded well.Patients required admissions in the hospital for 3-10 days depending upon the condition of the patient.

3) Platelet count showed improvement after giving Guduchi Kwath.

4)Helpful in hepatitis and hepatomegalae

5) Wherever RDP ,SDP given improvement was in the platelet count seen. Few patients needed multiple transfusions.

6) Patients were discharged after improvement in the platelet count > 150000/cmm.

7) Guduchi Kwath continued for 3-7 days after discharge to every patient.

8) Every patient asked for follow-up after 3 days after discharge and each and every patient was investigated for haemogram and specifically platelet count .LFT also was done .Improvement in the platelet count and leucocytes were noted. Deranged LFT’s showed improvement.

Role of Guduchi and Tikta Rasa

            Charakacharya has quoted that for Doshapachan and Shaman,decoctions made from Tikta Rasa are advisable.As Tikta Rasa is having  prominently  Vayu and Akash Mahabhuta ,the Dravyas having Tikta Rasa are Laghu,cleans the Strotas,have Sheetaveerya and does the Pachan.By Agnivardhan property,these Dravyas act on Agnimandhya,Aam and Pittanubandh,thus helps in the pathogenesis (Samnya Sampraptibhanga) of Jwar (fever). Thus Guduchi having Tikta and Katu Rasa does Agnideepan, Aampachan

            Guduchi is antibacterial,anti-pyretic, immunomodulator,analgesic,having no any kind of toxicity,hepatoprotective,anti-inflammatory,antimicrobacterial, Smooth muscle relaxant,antioxidant,cardioiprortective  hopoglycemic activity and thus helps in dengue haemmoraghic fever.

Conclusion

1) Guduchi Kwath in the dose of 40 ml mor-evening in the denguhaemorragic fever showed improvement in the platelet count

2) This can be used as a single drug in uncomplicated cases.

3) Helps in lowering the temperature.

4)Helps in relieving the maculopapular rash .

5) Helpful in hepatitis and hepatomegalae

6) Works as an  antiallergic and antihistaminic

7) No any kind of side effect of the Guduchi Kwath seen

8) It’s a good appetizer.Shows overall improvement.

9) No side effects seen

10) More blind studies are needed.

References

Modern

1) Robbins Basic Pathology;7^th edition ;2005;Saunders ;An Imprint of Elsevier; New Delhi

 2) Harrison’s Principles of Internal Medicine, 17th Edition, Vol I and II. Editors –

   Fauci.braunwald.Kasper.Hauser Longo. Jameson.Loscalzo; Mc Graw Hill Medical

 3) K sembulingam, 5^th edition, essentials of medical physiology,jaypee brothers,medical  publishers, new Delhi

4)  Dr. Sujit k. Chaudhari, 2^nd  edition, quintessence of medical    pharmacology, new central book agency,Calcutta

5)  Stephen j. McPhee, 51^st edition 2012 current medical diagnosis & treatment,  cenveo

      publisher services.

6)   Principles and practice of medicine; 16th edition.Davidson

Ayurved

1) Editor Pandyea G.S.(6^thedi.) Charak Samhita, Chaukhamba publications Varanasi

Nidan Sthana- 1/5,1/24 ,1/40,1/8,

Chikitsa Sthana -2/4 ,3/13, 3-26, , 3/29,3/31, 3/32,3/35,3/36,3/53-60,3/63-65,3/66,3/139, 3/329,3/330-335, 3/339-343

2) Dr.Ambikadatta Shastri, Editor,(14^th edi) Susruta Samhita ,Chaukhamba Publications

     Varanasi.

Uttartantra-39 /15,39/16-22,39/26, 39/163, 39/321,

3) Shri.Lalchandra Vaidya,Editor (6^th edi)Ashtang Hrudayam ,Motilal Banarasidas Varanasi4

Nidan Sthan- 1/1 1/60-63, 2/6,2/56-57,2/59,2/70

Chikitsa Sthan- 1/2 ,1/3 ,1/21,

4)  MadhavNidan -Narendranath Shastri (edi 5^th 2005),Motilal Banarasidas Varanasi

    1-Nidanpanchakam   

    2- Jwarnidanam- 32, 36-38, 74,75,78

5) Bhavprakash Nighantu Haritakyadi Varga .K.C.Chunekar Teeka, editor Dr.Gangasahay

     Pande, Chaukhamba Charati Academi ,Varanasi 2010 edition

6)   Sharandhardhar Samhita Madhyamkhand 2/1-2

Name                                  - Prof .Dr.D.L.Shinde

Educational Qualifications –MD;PhD (Kayachikitsa), Pune University

Permanent Address            - Bharati Vidyapeeth University ,College Of

                                              Ayurved,Katraj-Dhanakawadi,Pune-43

Date Of birth                      - 3^rd April, 1968

Family background            - I belong from a respectable farmer’s family.

Qualities                            – Hardwork,Honesty, Integrity, Peaceful, Enthusiastic,                                                                       Accommodative  & tough

Area Of Specilization Studies

1)      Diabetes, Hypertension, Atherosclerosis ,Metabolic Syndrome, cardiac diseases

2)       Muscosketal disorders,Spinal Cord injuries, Nervous System Disorders & Rehabilitation.

3)      AIDS & related infections

Work Experience

Teaching & clinical experience for 22 yrs. Research Guide for MD and PhD

Book published – Anna He PurnaBrahma, Executive Editor – Arogya Sarita –monthly magazine

Lectures on Pune Akashwani

Lectures at social organizations ,conducting  CME for medical fraternity

Organizing medical camps

Lectures as Resource person

Ongoing Research Projects

1) Studying the genotypic association of certain SNPs in patients with osteoarthritis of knee in Indian population for early diagnosis  of OA. At  IRSHA,BUU,Pune

2) The efficacy of Vangamrita-Yog in the management of Diabetic Neuropathy.At College of Ayurved ,BVU,Pune

3) Clinical Study to evaluate  the efficacy of Haritakyadi churna  in essential  hypertension. At College of Ayurved ,BVU,Pune.