Treatment and prevention of exacerbations of rheumatoid arthritis is an important medical and social problem. The disease gives a high level of disability (up to 70%), spread mainly among the able-bodied population. The pharmacotherapy of rheumatoid arthritis is not only not effective enough, but also has a large number of side effects that worsen the quality of life. The search for effective treatments is warranted. The experience and capabilities of Ayurvedic medicine can be considered as an opportunity to provide more effective assistance to this category of patients.
Rheumatoid arthritis (RA) is a chronic systemic autoimmune disease of the connective tissue with a primary lesion of the peripheral joints of the type of erosive-destructive polyarthritis. The etiology is finally unknown. There are several theories – autoimmune, viral (Epstein-Barr virus). The hereditary nature of the disease is also assumed. In Ayurveda, a group of diseases similar in symptoms to RA is called Amavata.
Etiology (Hetu, Nidana): According to the theory of Ayurvedic medicine, the cause of this disease is that Ama (the toxic product of undigested food) moves throughout the body with unbalanced Vata and is populated in the joints (sandhistana).
Modern medicine speaks of the decisive role of the violation of the immune response with the imbalance of immunocompetent cells and the violation of their functional activity. As a result of the interaction of macrophages, T-lymphocytes and B-lymphocytes, antibodies are produced that, when combined with the antigen, form immune complexes that trigger a cascade of immune-inflammatory reactions. Autoantibodies are formed against their own immunoglobulins of the IgG and IgM classes, called rheumatoid factors. Immune inflammation in the synovial membrane of the joints, which is supported by a high concentration of autoimmune substances, plays an important role in the progression of the disease.
In RA, the joints are affected mainly, but the skin, blood vessels (in the form of vasculitis), muscles, and internal organs (heart, lungs) can also be affected.
Ayurvedic medicine says, due to a decrease in digestive fire (jatharagni), food is not completely digested, it accumulates in the digestive system (amashaya) like ama (toxins). With a concomitant imbalance of the Vata dosha, Vata Ama moves Vata throughout the body and accumulates mainly in the joints, pelvic region (trica), and also in other organs.
In “Sushruta Samhita” the following reasons for the development of the state of Amavat are indicated:
- viruddhaahara (malnutrition);
- viruddhachesa (bad habits);
- mandagni (weak digestive agni or poor appetite);
- nishchalata (lack of physical activity);
- snigdhavuktavatovyama (physical activity after eating);
- nidanarthakar horn (pathological diseases);
- garbhasrab and garbhapata (frequent spontaneous or medical abortions);
- panda (anemia).
If a person eats food in such emotional states as atichinta (stress), shock (sadness), krodha (anger), bhaya (fear), then this contributes to the development of Amavat.
Clinical presentation (Pratyamatarupa): The leading feature in the clinical presentation is articular syndrome. The onset of the disease is subacute or persistent, characterized by polyarthritis. At the onset of the disease, the 2 and 3 metacarpophalangeal and proximal interphalangeal joints are most often affected. Subsequently, the metatarsophalangeal, wrist, knee, elbow, ankle and other joints are involved in the pathological process.
Joint syndrome is characterized by the following symptoms:
- Joint pain;
- Swelling of the joints;
- Stiff joints, especially morning stiffness;
- Pain during movement;
- Joint deformation;
- Pain during movement.
In the early phase of the lesion, inflammatory edema predominates, the joints are hot to the touch, the movements in them are painful and limited. In the future, deformation of the joints develops. Subluxations and joint structures are formed, “ulnar deviation” is formed – the hands take the form of a “walrus fin”, as well as deformation in the form of over extension of the fingers in the proximal and compensatory flexion in the distal interphalangeal joints — deformation of the wrist according to the “swan neck” type. In the popliteal fossa, a Baker cyst may form. There are also lesions of the joints of the foot.
– rheumatoid nodules are formed in the periarticular tissues, especially on the extensor surface. With histology, a necrosis (fibrioid) zone is found in the center. Most often, the nodules are located in the area of the elbow joint, the Achilles tendon is painless 2-3 cm in diameter.
Other extraarticular symptoms:
- temperature rise;
- decreased appetite;
- muscle weakness and atrophy, trophic changes.
Internal organs can also be affected (vicarious lesion)
– heart damage is, as a rule, the nature of myocarditis and persistent tachycardia. Rhythm and conduction disturbances on the ECG can be detected. Pericarditis may occur (diagnosed sonographically) – lung damage is manifested by dry or exudative pleurisy, alveolitis, it is possible to attach a case of bacterial infection;
– rheumatoid vasculitis is one of the characteristic manifestations of a systemic lesion that develops in severe forms of RA and a high titer of rheumatoid factor in blood serum. Important symptoms: ecchymosis, polymorphic rash, cerebral and abdominal syndromes;
– kidney damage: glomerulonephritis is more common, which can develop as a result of taking medications (NSAIDs and gold preparations);
– eye damage is in the nature of scleritis, iridocyclitis, etc.
– Anemic syndrome occurs in half of patients with RA and may be due to chronic inflammation and impaired iron metabolism. Hypochronic anemia can occur due to prolonged use of NSAIDs, initiating the development of erosion and stomach ulcers.
In the hemogram in patients with RA, anemia is often observed, a decrease in white blood cells (less often an increase in white blood cells), an increase in ESR (an increase in the concentration of C-reactive protein, an increase in alpha and gamma globulins, an increase in platelets, an increase in eosinophils.
Rheumatoid factors (antibodies of the IgG and IgM classes) are markers of autoimmune disorders. Antibodies to cyclic citrulline peptide (ADC, Anti-CCP) are recognized as a very specific (serological) marker of RA. According to some reports, it is even more specific than the rheumatoid factor. The dynamics of the radiological changes corresponds to the evolution of the pathological process of RA.
When formulating the diagnosis, one should take into account the clinical and anatomical characteristics of the process (poly-oligo-monoarthritis), the presence of systemic lesions (visceritis), mmunological characteristics (seropositive, seronegative), the peculiarity of the course (rapidly or slowly progressing), stages according to radiological data (1,2 , 3.4 stages) and degrees of activity (according to clinical and laboratory data) (1.2 and 3 degrees)
The classification of Amavat in Ayurveda is based on the predominance of symptoms of a disorder in one of the doshas:
Vataja – sharp pain is characteristic.
Pittanubandhi – redness and burning predominate.
Kaphanubandhi – impaired mobility and itching.
Vata also provokes colic, body pain, dizziness, joint stiffness and weakness of the muscles of the back and limbs, vasospasm, Pitta – fever, light-headedness, dizziness, Kapha – vomiting and nausea, anorexia, indigestion, fatigue, lethargy and heaviness.
In modern medicine, the following groups of medicines are used to treat RA:
NSAIDs (non-steroidal anti-inflammatory drugs) – diclofenac, ibuprofen, nimesulide, meloxicam
Glucocorticoids are prednisone.
Side effects of NSAIDs: gastrointestinal ulcers, anemia. very glucocorticoids cause an increase in glucose levels, weight gain, the development of Itsenko-Cushing’s syndrome.
As a basic therapy, drugs are applied that act on the links of pathogenesis:
- Quinolone preparations-chloroquine, hydroxychloroquine
– Gold preparations-chrysanol. It is noteworthy that already in one of the ancient Ayurvedic treatises “Madhava nidana samhita” gold preparations were mentioned. Modern medicine has also found application for them. In recent years, in modern treatment, gold preparations are rarely used because of their many side effects and low effectiveness.
Ayurvedic treatment of RA – Amavata
In the treatment of Amavat Ayurveda uses the following measures:
1. Langhana fasting and eating very light meals.
Recommended foods (pathya): warm hearth, pippali, shunthi (dry ginger), leafy green vegetables, garlic, fresh ginger, nim, barley, rice.
Recommended to be excluded (apathya): cold water, fish, black mung bean, sweets, cottage cheese, salty foods, cold drinks, fast food.
2. Shodhana Chikitsa (cleansing therapy), which includes a set of the following procedures included in Panchakarma:
- dipanpachan – the use of bitter and acute drugs that increase AGNI, contributing to the removal of ama: shunthi, pipali, guduchi, chitraka;
- virechana – laxative therapy with a tool such as castor oil;
- basti – anuvasana, oil enema, with oils such as sandhyavadi, mahanarayana, kottamchukadi and asthapana or niru – enema with a decoction of medicinal herbs;
- Svedana – at Amavat they use the dry sweating procedure in the form of dry sweating of rukshasved;
- Snehapana – ingestion of medicinal oil with nirgundi, cottamchukadi, lasunadi, dashamul herbs.
3. Shaman Chikits (symptom relief therapy)
Includes the use of drugs inside:
- quatamas, or broths – dashamul, rasonadi, panchakola, rasonpanchak;
- churna (powders) – shunthi, pachkol, nirgundi, rason (lason-garlic), him;
- vati (tablets, capsules) – amavatri, shalaki, chitrakadi, raason, him, yogorajguggul, sihnadguggul, sunthiguggul;
- ghrta (or ghruta) – preparations based on ghee shuntkhighrta (ghruta), rasnadighhrita (ghruta).
Topical application of medicinal formulations:
- tailam (vegetable oils with medicinal additives) – sandhyavadya, makhanarayana, orenda (castor oil);
- lepa (ointment) – shunthi, nirgundi.
- pranayama (bhastrika, anulom / vil, bahyapranayama);
- therapeutic yoga (dhanurasana, bujangasana, suryanamaskar, etc.).
Not recommended – vegavadharana (suppression of natural desires), daytime sleep, stay in the cold.
Prognosis (sadhyasadhyata): RA reduces life expectancy, leads to permanent disability. With an early diagnosis, at a young age, with a violation of one dosha and with appropriate treatment, the prognosis is favorable.
With the involvement of many doshas, with multiple organ failure, the prognosis is poor, in the presence of complications – life-threatening.
Timely diagnosis and treatment, the right lifestyle are important. The favorable outcome is facilitated by the inclusion of Ayurvedic medicine methods in the modern treatment regimen.