Int J Ayu Pharm Chem
ISSN 2350-0204 www.ijapc.com
November 10
th
2020 Volume 13, Issue 3 Page 6
A Randomised Controlled Clinical Study to
Evaluate the Effect of Vardhamana Pippali
Rasayana in the Management of Vatarakta w.s.r. to
Gouty Arthritis
Author: Shreyashri Suvarna
1
Co Authors: Itnal R. Shobha
2
1,2
Department of Kayachikitsa, Shree J.G.C.H.S. Ayurvedic Medical Ghataprabha, Belagavi, Karnataka, India
INTRODUCTION
Vatarakta is one of the major diseases mentioned
under Vatavyadhi caused due to vitiation of Vata
and Rakta by their own nidanas. The word
Vatarakta is made up of two words, ‘Vata’ and
‘Rakta’. Even though it is mentioned under
Vatavyadhi, a separate chapter has been dealt for
this disease by Charaka because of importance of
vishesha sampraptighataka of both Vata and
Rakta. Different other synonyms have been
mentioned in classics like adhyavata, khudavata
and vatabalasa based on its importance, lakshana,
upadrava and vyaktasthana. Vata having the
quality of chala guna helps in the movement of all
ABSTRACT
Vatarakta is a painful disease that initially involves small joints. This disease is caused due to consumption of
rakta pradoshaka ahara vihara along with vataprakopaka nidanas, both rakta and vata gets vitiated. In
modern science a condition called Gouty arthritis had similar presenting features hence it can be co-related to
Vatarakta. The main involvement of causative factor here is Vata and Rakta. Naimittika Rasayana is one of
the important therapeutic concepts in Ayurveda that is helpful in treating the disease and rebuilding the
damaged tissue thus helping to recover from prevailing disease. A randomised controlled clinical study was
conducted to evaluate the effect of vardhamana pippali rasayana in the management of vatarakta. Objective:
To compare the efficacy of Guduchi Rasayana and Vardhamana Pippali Rasayana in Vatarakta. In this study
vardhamana Pippali Rasayana which is also having vata-shleshmahara, deepana, vrushya action is
administrated. Minimal research has been conducted on effect of Rasayana on Vatarakta hence the present
research work was carried out. Study design: Randomized open controlled clinical study on patients having
signs and symptoms of vataakta/Gouty arthritis with pre-test and post-test on 30 patients divided in two groups
A and B. Result: when results were obtained it showed marked improvement in the overall signs and
symptoms as per the statistical analysis. Conclusion: Both vardhamana pippali Rasayana and Guduchi are
found to be effective in the treatment of Vatarakta.
Key Words: Vatarakta, vadhamana pippali, Rasayana, Gout
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dosha and dhatu. Rakta is a circulatory dhatu
which provides nourishment to all cells of the
body. Due to consumption of rakta pradoshaka
ahara vihara along with vataprakopaka nidanas,
vata and rakta independently gets aggravated by
its own nidanas, rakta further obstructs the vata
dosha and produce the disease
1
. Raktavaha srotas
is mainly exaggerated in this disease. Vatarakta
mainly affects the lower extremities and the
peripheral blood vessels in the initial stage.
Vatarakta is also caused by margavarana of vayu
by medas resulting in medasavruta vata. So it is
also considered as avaranajanya vyadhi. It is also
called as kudavata, adyavata and vatabalasa on
the basis of its severity and importance.
In the view of western medicine Vatarakta has
similar features of multiple disorders including
arterial as well as venous diseases, collectively co-
related as peripheral vascular diseases and an
arthritis called as Gouty arthritis.
Gout is a true crystal deposition disease. It refers
to a disease which occurs in response to the
presence of monosodium urate (MSU) crystals in
joints, bones and soft tissues. It may result in acute
arthritis and a chronic arthropathy. MSU crystals
preferentially deposit in peripheral connective
tissues in and around synovial joints, initially
favouring lower rather than upper limbs and
especially targeting the first metatarsophalangeal
joint and small joints of feet and hands.
Hyperuricemia is a common pathogenic factor in
the development of gout. Initially affects first
metatarsophalangeal joint, but may become
polyarticular in later episodes. It leads to
significant pain and afflicts patient’s health related
quality of life
2
.
Gout is the common inflammatory disease in men
aged more than 50yrs. Globally, gout affects 1-2%
of the population with strong male predominance
of ratio >5:1. By 2013 a report showed that about
8.3 million people suffered from this disease
3
. In
India, Gout is the most common form of
inflammatory arthritis. It is commonly seen in men
than in women. The incidence rate in men is 5-27
per 1000men. Gout rarely occurs in children and
in women before menopause
4
. Raised uric acid in
children is in-born errors of metabolism.
Ayurveda plays an important role in treating
metabolic disorders. It targets the whole system
ensuring to treat the root cause of the disease.
Rasayana chikitsa is a form of chikitsa in which
both prevention as well as treatment of disease is
explained with different formulations.
Vayasthapana, ayushkara, balakara and
jaravyadhinashana are the important clinical
functions of Rasayana. It not only improves the
health but also helps in longevity. Naimittika
Rasayana is one of the important therapeutic
concepts in Ayurveda explained under the concept
of Rasayana, helpful in treating the disease and
rebuilding the damaged tissue thus helps to
recover from prevailing disease.
Pippali having katu rasa, ushna veerya, madhura
vipaka with laghu, snighda and teekshna guna
which is having vata-shleshmahara, deepana,
vrushya and Rasayana action
5
. It is mainly
indicated in shoola. Vardhamana Pippali
Rasayana is indicated in vatashonita vikara
6
.
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Guduchi is a drug of choice and it acts as
Rasayana in Vatarakta
7
. There is minimal
research conducted on Rasayana effect on
Vatarakta hence this research work is carried out.
AIMS AND OBJECTIVES
To study Vatarakta and gouty arthritis in detail.
To evaluate the efficacy of Vardhamana Pippali
Rasayana in the management of Vatarakta.
To compare the efficacy of Guduchi Rasayana
and Vardhamana Pippali Rasayana in Vatarakta.
To evaluate the therapeutic effect of Rasayana
on quality of life in patients suffering from
Vatarakta
MATERIALS AND METHODS
Source of Data:
A. Literary Source: Reference of Vatarakta from
Ayurvedic classical text books, Journals, Research
Articles and References of Gouty arthritis from
updated modern text books
B. Clinical Source: Patients suffering from
Vatarakta will be selected from OPD/IPD of Shri
JGCHS Ayurvedic Medical College and Hospital
Ghataprabha, from Medical Camps and other
sources.
C. Drug Source: Drugs will be collected after
authentication from the Dept of Dravyaguna.
Method of Collection of Data:
Study Design
Randomized open controlled clinical study with
pre-test and post-test on 30 patients divided in two
groups A and B.
Diagnostic Criteria:
Diagnosis was established on the Basis of History,
Inspection, Signs and Symptoms of Vatarakta
Inclusion Criteria
Patients of Either Sex Between the age group
from 20 to 60 Yrs
Patients Presenting with clinical features of
vatarakta
Patients presenting clinical features of Gouty
arthritis with Hyperuricemia.
Exclusion Criteria
Patients with Uncontrolled Diabetes Mellitus,
Systemic Disorder and Endocrine Disorder.
Patients with Auto-Immune Disorders Of Joints,
infective and reactive arthritis.
Patients with Severe Toxicity, Ulceration,
Progressive Gangrenous Changes.
Patients with Infections and Communicable
Diseases.
Pregnant Women and Lactating Mother.
Duration of the Study
Treatment duration: 34 to 40 days
Follow up: 30 days
Total duration: 64 to 70 days
Patients are assessed before treatment, after
Shodhana, after Rasayana and once in every
15days for a month during follow up.
Intervention
Method of Administration
It is a clinical interventional study on 30 patients
divided in to two groups a and b. Subjects are
selected on the basis of classical signs and
symptoms of Vatarakta with detail history taking
and physical examination as per case proforma.
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Details of administration of drugs in trial
group A is mentioned in Table 1
Table 1 Method of administration of drugs in Trial Group A
1. Group A- Trial Group
Day
Procedure
Drugs
Ingredients
Anupana
1-3
Deepana and
Pachana
Shiva Kshara Pachana
Choorna
8
Hingwastaka
Churna
Haritaki Churna
Sarja Kshara
Sukoshna
Jala
4-10
Shodhana
Snehapana
Amrita Ghrita
9
(Guduchi and
Shunti)
Sukoshna
Jala
Abhyanga
Tila Taila
-
Bhashpasweda
Dashamoola
Kashaya
-
Virechaka
Haritakyadi Yoga
10
Sukoshna
Jala
11-15
Samsarjana Karma
Diet
-
-
16-34
Rasayana
Vardhamana Pippali
Rasayana
Pippali
Dugdha
Pathya
Shashtika Shali with
Dugdha and Ghrita
-
-
Vardhamana Pippali Rasayana Dosage
11
Ingredient: Pippali (Piper longum) , dosage is shown in Table 2
Table 2 Dosage of pippali
Days
Qty In No.
Grams
Anupana
Days
Quantity
In No.
Grams
Anupana
D1
3
1
Dugdha 200ml
D11
27
9
Dugdha 200ml
D2
6
2
Dugdha 200ml
D12
24
8
Dugdha 200ml
D3
9
3
Dugdha 200ml
D13
21
7
Dugdha 200ml
D4
12
4
Dugdha 200ml
D14
18
6
Dugdha 200ml
D5
15
5
Dugdha 200ml
D15
15
5
Dugdha 200ml
D6
18
6
Dugdha 200ml
D16
12
4
Dugdha 200ml
D7
21
7
Dugdha 200ml
D17
9
3
Dugdha 200ml
D8
24
8
Dugdha 200ml
D18
6
2
Dugdha 200ml
D9
27
9
Dugdha 200ml
D19
3
1
Dugdha 200ml
D10
30
10
Dugdha 200ml
Details of administration of drugs in trial group B is mentioned in Table 3
Table 3 Method of administration of drugs in control Group B
Group B – Control Group
Day
Procedure
Drugs
Ingredients
Dosage
Anupana
1-3
Deepana and
Pachana
Shiva Kshara Pachana
Choorna
Hingwastaka Churna
2gms twice daily
before Food
Sukoshna
Jala
Haritaki Churna
Sarja Kshara
4-10
Shodhana
Snehapana
Amrita ghrita (guduchi
and shunti)
Starting With 50ml
upto Adhastad
Sneha Darshana and
Samya Siddha
Laxana
Sukoshna
Jala
Abhyanga
Tila Taila
Q.S
-
Bhashpasweda
Dashamoola Kashaya
Q.S
-
Virechaka
Haritakyadi Yoga
Initial 1
karsha(12gm) and
increased depending
upon koshta.
Sukoshna
Jala
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11-15
Samsarjana
Karma
Diet
-
-
-
16-34
Rasayana
Guduchi Rasayana
Guduchi Khanda Churna
6gms
12
OD
Dugdha
Pathya
Pathya mentioned in
vatarakta.
-
Depending upon
koshta
-
Assesment Criteria
Subjective Parameters
Sandhi Graham
Sandhi Shoola
Spurana
Sandhi Shotha
Daha
Sparsha Asahishnuta
Twak Vaivarnya
Functional ability and disability
Objective Parameters
Esr
Serum Uric Acid
OBSERVATIONS AND RESULT
Stastistical analysis of the Objective Criteria by
unpaired‘t’ Test between the Group A and
Group B
Statistical analysis between the Group A and
Group B effect of therapy on ESR Before
treatment and after treatment by showing their
mean score values is showed in Table 4 and Figure
1.
Table 4 Between the Group A and Group B effect of therapy on ESR Before treatment and after treatment by showing their mean
score values
ESR
N
Mean
SD
SE
df
‘t’ Value
P Value
Group A
12
-9.33
7.96964
2.30064
25
-2.501
0.019
Group B
15
-3.40
4.1369
1.06815
25
-2.339
0.033
Figure 1 Between the Group A and Group B effect of therapy
on ESR by showing their mean score values
Between the group A and group B analysis
of ESR, showed significant difference in Group A
then Goup B
Statistical analysis the Group A and Group
B effect of therapy on Serum Uric Acid Before
treatment and After treatment by showing their
mean score values Table 5 and Figure 2.
Table 5 Between the Group A and Group B effect of therapy on Serum Uric Acid Before treatment and After treatment by
showing their mean score values
Serum Uric
Acid
N
Mean
SD
SE
df
‘t’ Value
P Value
Group A
12
-.4667
0.17753
.05125
25
-2.070
.049
Group B
15
-.3067
0.21536
.05561
25
-2.116
.045
-9.33
-3.4
-10
-8
-6
-4
-2
0
Goup A Group B
ESR
Mean diff of ESR
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Figure 2 Between the Group A and Group B effect of
therapy on Serum Uric Acid Before treatment and after
treatment by showing their mean score values
Between the group A and group B analysis of
ESR, showed no significant difference in Group A
then Group
Stastistical analysis of the subjective Criteria
by Wilcoxon Signed Rank Test within the Group A
and Group B shown in Table 6
Table 6 Stastistical analysis of the subjective Criteria by Wilcoxon Signed Rank Test within the Group A and Group B
Stastistical analysis of the subjective Criteria
by Mann Whitney Test between the Group A and
Group B Table 7.
DISCUSSION
Effect on therapy
Objective criteria
As per statistical analysis made in Table 4 and
Table 5
Between the group A and group B analysis of
ESR, showed significant difference in Group A then
Goup B, vardhamana pippali Rasayana found to
have better result.
-0.466
-0.306
-0.5
-0.4
-0.3
-0.2
-0.1
0
Group A Group B
Serum Uric Acid
Mean diff of S.
Uric Acid
Parameter
Group
Negative Rank
Poisitive Rank
Ties
Total
Z value
p value
Inference
Sandhi graha
N
MR
SR
N
MR
SR
Group A
BT-AT
12
6.50
78.
00
0
0.0
0.0
0
12
-3.134
0.002
H.S
Group B
BT-AT
14
7.50
105
.00
0
0.0
0.0
1
15
-3.372
0.001
H.S
Sandhi Shoola
Group A
BT-AT
12
6.5
78.
00
0
0.0
0.0
0
12
-3.217
0.001
H.S
Group B
BT-AT
15
8.0
120
.0
0
0.0
0.0
0
15
-3.535
0.000
H.S
Sandhi
Sphurana
Group A
BT-AT
8
4.50
36.
00
0
0.0
0.0
4
4
-2.714
0.007
H.S
Group B
BT-AT
9
5.00
45.
00
0
0.0
0.0
6
15
-2.810
0.005
H.S
Sandhi Shotha
Group A
BT-AT
12
6.50
78.
00
0
0.0
0.0
0
12
-3.134
0.002
H.S
Group B
BT-AT
14
7.50
105
.00
0
0.0
0.0
1
15
-3.372
0.001
H.S
Daha
Group A
BT-AT
11
6.0
66.
00
0
0.0
0.0
1
12
-3.125
0.002
H.S
Group B
BT-AT
13
7.00
9.0
0
0
0.0
0.0
2
15
-3.236
0.001
H.S
Sparsha
Asahishnuta
Group A
BT-AT
11
6.0
66.
00
0
0.0
0.0
1
12
-3.017
0.003
H.S
Group B
BT-AT
11
6.0
66.
00
0
0.0
0.0
4
15
-2.994
0.003
H.S
Twak
vaivarnya
Group A
BT-AT
6
3.50
21.
00
0
0.00
0.00
6
12
-2.333
0.020
S
Group B
BT-AT
11
6.00
66.
00
0
0.0
0.0
4
15
-3.207
0.001
H.S
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Between the group A and group B analysis of
ESR, showed no significant difference in Group A
then Goup B. vardhamana pippali Rasayana found
to have better result.
Table 7 Stastistical analysis of the subjective Criteria by Mann Whitney Test between the Group A
and Group B
Between the group A and group B analysis
of Serum Uric Acid, showed significant difference
in Group A then Goup B, vardhamana pippali
Rasayana found to have better result.
Between the group A and group B analysis
of Serum Uric Acid, showed no significant
difference in Group A then Goup B. vardhamana
pippali Rasayana found to have better result.
Subjective criteria
As per statistical analysis made in Table 6 and
Table 7
1. Sandhi graha
When the results were obtained between the
group analysis (at the mean rank of subordinate
level of significance) of effect on Sandhi Graha, it
showed no statistical significant difference in both
the group. Group A showed better result
(MR=13.08)
This could be because of presence of anti-
inflammatory and anti-oxidative action of both
pippali and guduchi.
2. Sandhi Shoola
When the results were obtained between the
group analysis (at the mean rank of subordinate
level of significance) of effect on Sandhi Shoola,
it showed no statistical significant difference in
both the group. Group A showed better result
(MR=11.25)
Studies show that pippali and guduchi acts
as analgesics and has steroidal effects due to
presence of its chemical constituents. This may
have reduced the sandhi shoola.
3. Sandhi Sphurana
When the results were obtained between the
group analysis (at the mean rank of subordinate
level of significance) of effect on Sandhi
Sphurana, it showed no statistical significant
Parameter
N
Group
A
Group
B
Mean rank
Sum of rank
U
Value
Z
Value
p
value
Remarks
A
B
A
B
Sandhi shoola
AT-
BT
27
12
15
13.08
14.73
157.00
221.00
79.00
-
0.740
0.459
NS
Sandhi graha
AT-
BT
27
12
15
11.25
16.20
135.00
243.00
57.00
-
1.826
0.068
NS
Sandhi
Sphurana
AT-
BT
27
12
15
13.88
14.10
166.50
211.50
88.500
-0.81
0.935
NS
Sandhi shotha
AT-
BT
27
12
15
14.13
13.90
169.50
208.50
88.500
-0.80
0.936
NS
Daha
AT-
BT
27
12
15
12.38
15.30
148.50
229.50
70.500
-
1.053
0.292
NS
Sparsha
asahishnuta
AT-
BT
27
12
15
13.04
14.77
156.50
221.50
78.500
-
0.598
0.550
Twak
vaivarnya
AT-
BT
27
12
15
15.54
12.77
186.50
191.50
71.50
-
1.023
0.306
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difference in both the group. Group A showed
better result (MR=13.88)
4. Sandhi Shotha
When the results were obtained between the
group analysis (at the mean rank of subordinate
level of significance) of effect on Sandhi Shotha,
it showed no statistical significant difference in
both the group. Group B showed better result
(MR=13.90)
Both pippali and guduchi are proved to have
anti-inflammatory actions. This might have
resulted in the tremendous reduction of shotha in
the subjects.
5. Daha
When the results were obtained between the
group analysis (at the mean rank of
subordinate level of significance) of effect on
Daha, it showed no statistical significant
difference in both the group. Group A showed
better result (MR=13.38)
Due to anti-inflammatory action of the drugs,
the inflammation reduced thus reducing the
burning sensation.
6. Sparsha Asahishnuta
When the results were obtained between the
group analysis (at the mean rank of subordinate
level of significance) of effect on Sparsha
Asahishnuta, it showed no statistical significant
difference in both the group. Group A showed
better result (MR=13.04)
Due to anti-inflammatory action of the
drugs, the inflammation reduced thus
reducing the tenderness in the joints
7. Twak vaivarnya
When the results were obtained between the
group analysis (at the mean rank of subordinate
level of significance) of effect on Twak
Vaivarnya, it showed no statistical significant
difference in both the group. Group B showed
better result (MR=12.7)
After srotoshodhana, circulation around the
joints was improved resulting in reduction in the
discoloration of the skin.
Probable mode of action of drug
The basic pathology in Vatarakta is Vata and
Rakta being aggravated independently due to its
etiological factors and mutually gets aggravated
and obstructed. This aggravated vata along with
Rakta dushti moves throughout the body and takes
sthanasamshraya at the padangushta sandhi due to
its vyadhi prabhava. This is told as anyonya
avarana by chakrapani. So Vatarakta is considered
as anyonya avaranajanya Vatavyadhi. Due to its
properties like sukshmatva and saratva of vayu,
dravatva and ushnatva of Rakta, they spread all
over the body. The spread is ashukari i.e. acute
manifestation, and it is facilitated by vyana vata.
Due to sushma sira and convoluted marga in
sandhi pradesha the aggravated dosha and dushya
gets lodged in smaller sandhies. This is why the
main and first site of manifestation is seen in
padamula, hasta mula and later spreads to other
sandhies in upward direction. The process of
spreading can be understood similar to that of rat
poison.
Pippali having snigdha, ushna and teekshna
quality helps in subsiding the aggravated vata, an
due to its madhura vipaka and it do not aggravate
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the Rakta dosha, perhaps due to its deepana,
pachana action it does sroto shodhana and relieves
the obstruction caused due to vata and Rakta.
Rasayana action of pippali improves the metabolic
function, strength and immunity of the individual.
The proteins of Piper longum are good
antioxidants as compared to standard antioxidants
and also having anti-inflammatory studies. The
study was conducted to find and evaluate
antioxidant activities of proteins isolated from
boiling water extract of Pippali showed that the
obtained results of proteins of Long pepper are
very promising and had anti-oxidant properties,
and it also showed that the pippali is non-toxic for
cells
13
. This action of pippali helps in the reduction
of inflammation in the disease Vatarakta. Once the
inflammation reduces other symptoms like pain,
swelling and redness also gets reduced. Along
with anti-inflammatory action the immune-
modulatory action of pippali plays an important
role in regaining the affected immunity and
strength of the individual. This can be a probable
mode of action of vardhamana pippali Rasayana.
Guduchi is having snigdha guna that helps to
subside ruksha guna of vata. Usually tikta rasa
converts into katu vipaka which cause vibanda,
but Guduchi exceptionally having madhura vipaka
expels pureesha etc. Tikta rasa subsides rakta and
madhura vipaka subsides vata. Guduchi as a
Rasayna dravya has balya (increases strength),
tridoshashamaka, deepaniya (appetiser), shotha-
hara (relieves oedma), vata-shonithara (subsides
gouty arthritis) properties
114
. It ultimately
increases the functioning of immune system of the
body. A study conducted showed the potential
antioxidant activities of guduchi leaf as well as
stem and it can be used as a source of antioxidant
for health benefits through dietary
supplementations
15
. This property helps in
reduction of pain and swelling in Vatarakta, and
augments the healing of the damaged tissue. This
can be the probable mode of action of Guduchi
Rasayana.
CONCLUSION
Vatarakta can manifest into two different ways
depending upon the nidana, predominance of
dosha, dushya and samprapti vighatana.It is one
among the unique disorders of Vatavyadhi. When
vata and rakta aggravates by its own etiological
factors and gets morbid with each other causing
the disease vatarakta is the one form of samprapti.
Other is the one when the kapha and medas get
involved in the pathology of vatarakta causes the
margavarana of the morbid dosha. Both are said to
have the severe impact on the formation of the
disease. As it is a disease caused by the metabolic
impairment, in the conventional system of
medicine it can be co-related to the multiple forms
of the disease having different forms of signs and
symptoms including Gouty Arthritis, peripheral
artery diseases, and periphery venous disease.
Even though various chikitsa are mentioned in the
classics, the selection of the treatment is solely
depends upon the rogi bala and vyadhi bala. As per
statistical evaluation of the present study, both
vardhamana pippali Rasayana and Guduchi are
found to be effective in the treatment of Vatarakta.
Int J Ayu Pharm Chem
ISSN 2350-0204 www.ijapc.com
November 10
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2020 Volume 13, Issue 3 Page 15
No severe complications were observed during the
study.
Int J Ayu Pharm Chem
ISSN 2350-0204 www.ijapc.com
November 10
th
2020 Volume 13, Issue 3 Page 16
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