IntroductionDiabetesMellitus is a chronic, heterogeneous and life threatening disease. The prevalence of diabetes in 2014 was 382million which was estimated to scale up to an alarming 592 million by 2035 bythe International Diabetes Federation (IDF). Nearly 80% of people with diabetesare in the low and middle income countries 1. Moreover greater than 60% of world diabetespopulation will be in Asia. India, Nepal and China have shown an increasingprevalence of diabetes even among the rural population.

2.  Theescalating rate of obesity is a major causative factor for increasing prevalence of Type2 diabetes (T2DM) 3,4.  Metabolicsyndrome is considered as the new epidemic of the twenty-first century.  It is a major andescalating public-health and clinical challenge worldwide in the wake ofurbanization, surplus energy intake, increasing obesity, and sedentary lifehabits 5.  MetS confers a 5-foldincrease in the risk of type 2 diabetes mellitus (T2DM) and 2-fold the risk ofdeveloping cardiovascular disease 6.

Further, patients with the MetS are at2- to 4-fold increased risk of stroke, a 3- to 4-fold increased risk ofmyocardial infarction (MI), and 2-fold the risk of dying from such an eventcompared with those without the syndrome 7 regardless of a previous historyof cardiovascular events 8.Thiscase illustrates the therapeutic potential of Ayurvedic mode of management in achronic T2DM patient with Metabolic syndrome where conventional treatment isunable to sustain the desired effects. It also tries to observe clinical reportingof any adverse drug interactions between ayurvedic and allopathy sytem of medication.  Further it emphasises the need to understand apatient based on Ayurvedic fundamental principles in order to decipher the unique’samprapti’ (mode of pathogenesis) ofthe disease before planning the intervention.

 Case presentationA55 yr old Indian male presented in May 2017 at OPD of Ayush Wellness Clinicwith complaints of poor glycaemic control inspite of taking oral hypoglycaemicmedication, hypertriglyceridemia and chronic constipation with fullness ofstomach, gas & abdominal bloating. Patient is diabetic for the past 10 yrsand constipation history is more than 20 yrs. Also presents history of hypertension for the past 21/2 yrsand hypertriglyceridemia for the past 1 yr. No history of any type of addiction was present.  His family history was positive forT2DM.  Whenfirst diagnosed in 2007 the patient was put on Glibenclamide 5mg.

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  With increasing blood sugar levels in July 2014the medication was changed to Metformin & Sitagliptin combination 500mg/50mgtwice daily.  In January 2015 whendiagnosed with hypertension was put on Ramipril 2.5 mg once daily.  In December 2015 the dose of Metformin &Sitagliptin combination has been increased to 1gm/50mg twice daily withaddition of Glimepiride 1mg once daily as the FBS was 155mg/dl and PP was 271mg/dl.  In December 2015 the dose ofRamipril has been increased to 5mg once daily as the blood pressure was notgetting controlled.

  At the time ofconsultation in May 2017 the patient was on Metformin & Sitalgliptin1gm/50mg twice daily and Ramipril 5mg once daily.  In March 2016 hypertriglyceridemia andborderline hypercholestraemia was detected was advised to control diet and doregular exercise.  The drug compliancewas good and diet & exercise were irregular.  With the oral hypoglycaemic medications theabdominal complaints got worsened and so stopped Glimiperide 1mg for the past 6months. Patient was not on any lipid lowering medication.Diagnostic evaluation &AssessmentAtthe time of consultation the blood reports showed FBS: 83mg/dl, PP: 218mg/dl, HbA1c:7.9%, Urea: 19mg/dl, Creatinine: 0.

7mg/dl, Total cholesterol: 182mg/dl, Triglycerides:275mg/dl, VLDL: 55mg/dl, HDL: 46mg/dl, LDL: 81mg/dl.  Patient BP was 130/85mmHg, weight 75 kg,height 171 cm and waist circumference 102cm. BMI was 26 which was overweight and waist circumference shows abdominalobesity.  Clinicallypatient was complaining of chronic constipation, fullness of stomach, gas andbloating of abdomen.  Patient isdiagnosed as Type II diabetes with Metabolic syndrome & chronicconstipation and on ayurvedic line as Avaranajanyamadhumeha with Vibanda. (Table 1 : Timeline)   (Table 2: Ayurvedic Parameters)Treatment & OutcomeAtfirst appointment on 30.0517 patient presented with poor glycaemic control, hypertriglyceridemia,constipation, fullness of stomach, gas & bloating.  He was put on the following ayurvedicmedicines: Phalatrikadi Kwath, MLiv Tablet,                         Lavanabhaskar Churna, Arogyavardinivati (Table 1 Timeline) and asked to continue oral hypoglycaemic  (metformin & sitagliptin 1gm/50mg BD)& antihypertensive (ramipril 5mg OD) medication as usual.

  Further given dietary and lifestyle advice.(Table 1 Timeline).Thesecond appointment on 14.06.17 included a review of laboratory results and anupdated symptom assessment.  The patientwas feeling much better, totally relieved with the GIT complaints and hislaboratory parameters also showed improvement, better regulation of blood sugarand total control of hypertriglycerides. Blood pressure was normal but noreduction in weight was observed.

  Aftertwo weeks of medication there was no adverse drug interactions reported. (Table1 Timeline)Thethird appointment on 20.06.17 included an updated symptom assessment.

  Patient was complaining again of constipationand hence supplemented with Eranda taila.(Table 1 Timeline)Thefourth appointment on 20.07.17 included a review of laboratory results and an updatedsymptom assessment.  Laboratoryparameters showed marked improvement and sustained the improvement noted ofearlier reading of third appointment. Patient was better with constipation and gas trouble.  Blood pressure was normal, no reduction inweight was observed and 2 cm reduction in waist circumference was noted.

  Patient was advised to stop M. Liv tablet andArogyavardini vati and continue theremaining medications. Again no adverse drug interactions reported and theLiver function tests and Kidney functions tests were within normal limits. (Table1 Timeline)DiscussionThrough its contribution tocardiovascular disease, stroke and mortality, the increasing prevalence of T2DMalong with Metabolic syndrome is a huge health challenge and an economic burdento the world.Ayurveda, the eternal systemof medicine, has documented various clinical conditions and their managementbased on its fundamental principles. Diabetes mellitus and Metabolic syndrome can be understood and managed basedon the principles of ‘Prameha’ (~umbrellaterm for various metabolic disorders involving pathogenesis of urinary system) especially’Sthula pramehi’/’Avaranajanya Madhumeha9.

AcharyaCharaka has mentioned that a physician need to examine the three importantfactors viz., Samuthana vishesha (thespecific causative factors for disease manifestation) Adhistana visesha (the site of manifestation of disease) and Vikara prakriti (the nature of diseasepathway) for successful management of the patient10.  As per ayurveda each andevery individual is unique and so his development of illness will also beunique as well as specific to the individual. Hence it is important to decipher the Visesha samprapti (specific mode of pathogenesis) in a patientbased on ayurvedic principles before administering the intervention.

In the present case for thepast 20 years, the patient is constantly suffering with gastric complaintsespecially constipation.  Due tosedentary lifestyle and unhealthy food habits with a family history of diabetesdeveloped T2DM 10 years back which eventually resulted in Metabolic syndrome.  Due to the chronic vitiation of Apana vata the agni dusti has occurred which further due to kapha, pitta, medo dusti kara ahara (diet) and vihara (regimen) resulted in themanifestation of Avaranajanya madhumeha/Sthula pramehi (T2DM).  This disease condition progressed with timeto manifest into a much severe pathology that resulted in Metabolicsyndrome.  Important principles of samprapti vighatana are as follows :·        Need to regulate and bring anulomagati (~normal movement) to Apana vataby removing the vibandha.  ·        Remove the aama (~metabolictoxins) & improve the agni – jataragni, bhutagni & dhatwagni (rasa, raktha & medo)·        Avaranajanya madhumeha/Sthula pramehi treatment to be adopted.

  ·        For sthula pramehi though Sodhana (~bio-purificatory therapy) isadvised here considering the chronicity of disease progression, avarana mode of pathogenesis and severe apana vata vitiation, Shamana (~pacifying therapy) treatmentwith mrudu (mild) sodhana is found to be more applicable.So the following treatmentprinciples are applied before selecting the medications: (Table 3: Rationality of therapeutics)Along with the abovemedication diet and lifestyle modification followed by the patient were also tobe considered for the encouraging results. No significant reduction in weight was observed but the patient wasfeeling more active and healthy.Because of lack of properdocumentation there is a serious doubt regarding the allopathy and ayurvedicdrug interactions.  This case documentsthat there are no adverse drug interactions.

LimitationsChronicconditions and their treatments are usually multifactorial, complicating theevaluation of cause-and effect relationship between symptoms and treatment. The results cannot begeneralised as the present case stresses the need for individualised approach. ConclusionChronic T2DM with Metabolicsyndrome is at risk of CVD and Stroke and better management will reduce therisks.

  This case demonstrates the needto stick to the classical therapeutic principles of ayurveda and apply themrationally to get the best possible outcomes and also throws light on the modelof integrated approach.  Theintegrated effect of the therapeutics as well as the patient’s choices andinvolvement contributed to the present outcome. Patient perspective’I feel totally relievedwith the GIT complaints which I was suffering since many years.  With better regulation of blood sugar I feelmore active, energetic and overall quality of life got much improved.’Informed consentAn informed written consent was obtained from thepatient for reporting this case.AcknowledgementsThis case report was prepared accordingto the CARE guidelines11.

 References:International Diabetes Federation (2013) IDF Diabetes Atlas.(6thedn). The global burden. 29-31.Ramachandran A,Snehalatha C, Shetty AS, Nanditha A (2012) Trends in prevalence of diabetes in Asian countries. World J Diabetes 3: 110-117.

Ramachandran A,Chamukuttan S, Shetty SA, Arun N, Susairaj P (2012) Obesity in Asia–is it different from rest of the world. Diabetes Metab Res Rev 28 Suppl 2: 47-51.Regional Office for the Western Pacific of the World Health Organization, International Association for the Study of Obesity and the International Obesity Task Force (2000) The Asia-Pacific perspective: Redefining obesity and its treatment.5.

   Jaspinder Kaur AComprehensive Review on Metabolic Syndrome Article · March 2014 DOI:10.1155/2014/943162 · Source: PubMed6.   K.

G. M. M. Alberti, R. H.

Eckel, S. M. Grundy et al.

, “Harmonizing the metabolic syndrome: a jointinterim statement of the international diabetes federation task force onepidemiology and prevention; National heart, lung, and blood institute;American heart association; World heart federation; Internationalatherosclerosis society; And international association for the study ofobesity,” Circulation, vol. 120, no. 16, pp. 1640–1645, 2009.

7.   K. G. M. M. Alberti and P.Zimmet, “The metabolic syndrome— a new worldwide definition,” The Lancet, vol.

366, no. 9491, pp. 1059–1062, 2005. 8.

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Van DerGraaf, J.-D. Banga, A.

Algra, T. J. Rabelink, and F. L. J. Visseren, “TheMetabolic Syndrome is associated with advanced vascular damage in patients withcoronary heart disease, stroke, peripheral arterial disease or abdominal aorticaneurysm,” European Heart Journal, vol. 25, no.

4, pp. 342–348, 2004.9.   Acharya Y.T.

, editor.Commentary Ayurveda Dipika of Chakrapanidatta on Charaka Samhita of Agnivesha,Sutra Sthana; Kiyantah siraseeya adhyaya: chapter 17, verse 78-82. Chaukhamba Sanskrit Samsthana; Varanasi:2001. p. 103.  10.Acharya Y.

T., editor.Commentary Ayurveda Dipika of Chakrapanidatta on Charaka Samhita of Agnivesha,Sutra Sthana; Trishotheeya adhyaya: chapter 18, verse 44-47. Chaukhamba Sanskrit Samsthana; Varanasi:2001.

p. 108.11.Gagnier J, Kienle G, AltmanDG, et al. The CARE Guidelines: Consensus-based clinical case reportingguideline development. J Clin Epidem.

67(1):46-51.   Table1 : Timeline  Date Presenting complaints 30.05.

17 Poor glycaemic control, hypertriglyceridemia, constipation, fullness of stomach, gas & bloating Date Past Medical History and Interventions More than 20 yrs Complaints of constipation, fullness of stomach, gas, bloating 2007 Detected with T2DM started Glibenclamide 5mg BD July 2014 Changed to Metformin & Sitagliptin 500mg/50mg combination BD January 2015 Detected with Hypertension started with Ramipril 2.5mg OD December 2015 Increased dose of Metformin & Sitagliptin to 1gm/50mg BD plus addition of Glimiperide 1mg OD December 2015 Increased dose of Ramipril to 5mg OD March 2016 Hypertriglyceridemia and borderline hypercholestraemia detected December 2016 Discontinued taking Glimiperide 1mg OD as it was worsening the abdominal complaints Details of Patient visit 30.05.17 14.06.17 18.07.17 Laboratory  biomarkers & other findings Fasting blood sugar 83 mg/dl 102 mg/dl 104 mg/dl Post prandial blood sugar 218 mg/dl 150 mg/dl 107 mg/dl Urea 19 mg/dl 16   mg/dl 15   mg/dl Creatinine 0.

7 mg/dl 0.8  mg/dl 0.8  mg/dl Total cholesterol 182 mg/dl 179 mg/dl 192 mg/dl Triglycerides 275 mg/dl 97 mg/dl 82 mg/dl VLDL 55 mg/dl 20 mg/dl 17 mg/dl HDL 46 mg/dl 49 mg/dl 53 mg/dl LDL 81 mg/dl 110 mg/dl 122 mg/dl HbA1c 7.9% — 7.

2% Total Bilirubin 0.5 mg/dl — 0.5 mg/dl Conjugated Bilirubin 0.1 mg/dl — 0.1 mg/dl SGOT 18 IU/L — 17 IU/L SGPT 38 IU/L — 35 IU/L Blood pressure 130/85 mmHg 115/75 mmHg 115/80mmHg Weight 75 Kg   75 Kg Height 171 cm     Waist circumference 102 cm   100 cm Diagnosis Avaranajanya Madhumeha with Vibanda – T2DM with MetS and chronic constipation Therapeutic Intervention Duration Medication Dose Frequency Anupana 30.05.17 to 20.06.

17 1.  Phalatrikadi Kwath   50ml   Twice a day before food     2.  M. Liv Tablet   2 tablets   Twice a day after food Warm water   3.  Lavanabhaskar churna   5 gm   Once daily before lunch Warm water   4.  Arogyavardhini vati 2 tablets Twice daily after food Warm water 20.06.17 to 18.

07.17   Continuation of the above medication and             5.  Eranda taila 5ml Evening before Food Phalatrikadi Kwath Lifestyle modification Advised to take more of green vegetables, Roti/Chappati, buttermilk, water ( luke warm) Avoid Curd, Rice, Fried food, excess salt, Pickles, etc. Advised to do light exercise like walking during early morning & evening hours Outcome Better and normal Glycaemic control, normal levels of triglycerides, regular bowel movements, complete reduction in gas trouble, abdominal bloating & constipation.

No adverse drug interactions reported.  Table 2: Ayurvedic Parameters Ayurvedic parameters Findings in the patient Dosha Tridosha with secondary vitiation of Vata (Avarana) (~occlusion) Dushya Rasa, Raktha, Medo (Clinically evident) Mamsa, Majja, Sukra, Ojas (Clinically not evident) Sthana (site of pathogenesis) Vapavaham, (~omentum) Vasty (~Urinary system) & Pakwasaya (~large intestine) Agni (~ biological fire) Jataragni:    Vishamagni (irregular appetite) Bhutagni:     Mandagni (decreased appetite) Dhatwagni:  Mandagni (Rasa, Raktha, Medo)   Srotas (channels of circulation) Annavahasrotas (~channels of digestive system) Mutravahasrotas (~channels of urinary system) Pureeshavahasrotas (~channels carrying faeces) Rasavahasrotas (~channels carrying plasma) Rakthavahasrotas (~channels carrying blood) Medovahasrotas (~channels carrying adipose tissue) Avastha (stage of disease) Aamavastha (stage of disease with Aama) Rogamarga (the pathway of disease manifestation) Abhyantara (Internal pathway) : Vibanda (Constipation) Madhyama (~Middle pathway) : Avaranajanya Madhumeha (T2DM)   Sadyaaasadyatva (prognosis) Krchrasadya (Difficulty to cure): Avaranajanya Madhumeha Sadya (Easy to cure): Vibanda  Table3: Rationality of therapeutics S.No. Name of the medicine administered Rationality 1 Lavanabhaskara churna Anulomana of Apana vata and to improve Jataragni 2 M Liv tablet Site of action is Yakrut (liver), adhistana (site) for Bhutagni.  Improving the bhutagni 3 Arogyavardhini vati Improving the bhutagni and dhatwagni especially medo dhatu 4 Phalatrikadi kwath Effective formulation in Prameha, mentioned to be tridoshaja 5 Eranda taila To cause the Apana vata anulomana.  It is administered along with Phalatrikadi kwath as after 3 weeks patient reported again with constipation.

  Initially Phalatrikadi kwath with Lavanbhaskar churna was able to relieve the vibanda by removing the Kapha avarana at apana and with the change of avastha to rookshata,(dryness) eranda taila was supplemented.