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|title=Amavata (Rheumatoid arthritis)

|title=Amavata  

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|keywords=Amavata, Rheumatoid arthritis, Charak samhita, carakasamhitaonline, Indian System of Medicine.

|keywords=Amavata, Rheumatoid arthritis, Charak samhita, carakasamhitaonline, Indian System of Medicine, Ayurveda, treatment of rheumatoid arthritis

|description=The conditon in which ama alomg with vitiated vata effects the joints

|description=The conditon in which ama alomg with vitiated vata effects the joints

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|image=http://www.carakasamhitaonline.com/resources/assets/ogimgs.jpg

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<div style='text-align:justify;'>

<p style='text-align:justify;'>The clinical condition in which aggravated [[vata]] is associated with metabolic toxins (ama) and mainly affects joints is termed as ‘amavata’. This condition closely resembles with rheumatoid arthritis. The main culprit behind this disease is the deranged digestion and metabolism (agni). Arthralgia, stiffness and swellings of joint are main clinical features. The treatment is focused to improve digestion and metabolism and maintain equilibrium of [[vata dosha]]. Detail description of amavata as a separate disease entity is observed in the text of Madhava Nidana.

The clinical condition in which aggravated [[vata]] is associated with metabolic toxins (ama) and mainly affects joints is termed as ‘amavata’. This condition closely resembles with rheumatoid arthritis. The main culprit behind this disease is the deranged digestion and metabolism (agni). Arthralgia, stiffness and swellings of joint are main clinical features. The treatment is focused to improve digestion and metabolism and maintain equilibrium of [[vata dosha]]. Detail description of amavata as a separate disease entity is observed in the text of Madhava Nidana.

<br/>A comparative study of the pathophysiology of this disease by [[Ayurveda]] and allopathic system reveals that modern medicine emphasizes on control of  inflammation with use of NSAIDS, immunosuppressants and TNF blockers. This is an “offence strategy” which has rapid response but needs to be continued indefinitely and has high incidence of toxicity. On the other hand [[Ayurveda]] follows primarily a “defense strategy” which takes longer time to control inflammation and the symptoms but incidence of toxicity is very little, if at all. In patients with acute inflammation and severe discomfort, initial treatment should be with immunosuppressants and TNF blockers. On control of acute symptoms ayurvedic treatment should be continued. This combined ([[Symbiohealth]]) approach in the management of disease can give insight into the genetic and epigenetic phenomenon and opens the doors for groundbreaking research.<ref>Basisht GK, Singh RH, Chandola H. Management of rheumatoid arthritis (Aamavata) using symbiohealth healthcare system. AYU [serial online] 2012 [cited 2021 Jul 24];33:466-74. Available from: https://www.ayujournal.org/text.asp?2012/33/4/466/110513</ref> This article describes the etiopathogenesis and management of amavata. </p>

A comparative study of the pathophysiology of this disease by [[Ayurveda]] and allopathic system reveals that modern medicine emphasizes on control of  inflammation with use of NSAIDS, immunosuppressives and TNF blockers.This is an “offence strategy” which has rapid response but needs to be continued indefinitely and has high incidence of toxicity.On the other hand [[Ayurveda]] follows primarily a “defense strategy” which takes longer time to control inflammation and the symptoms but incidence of toxicity is very little, if at all. In patients with acute inflammation and severe discomfort, initial treatment should be with immunosuppressives and TNF blockers. On control of acute symptoms ayurvedic treatment should be continued.This combined (Symbiohealth) approach in the management of disease can give insight into the genetic and epigenetic phenomenon and opens the doors for groundbreaking research.<ref>Basisht GK, Singh RH, Chandola H. Management of rheumatoid arthritis (Aamavata) using symbiohealth healthcare system. AYU [serial online] 2012 [cited 2021 Jul 24];33:466-74. Available from: https://www.ayujournal.org/text.asp?2012/33/4/466/110513</ref> This article describes the etiopathogenesis and management of amavata.  

'''National Ayurveda Morbidity Code''': EC-6

'''National Ayurveda Morbidity Code''': EC-6

'''ICD code''': M06.9

'''ICD code''': M06.9

'''Keywords''': Amavata, rheumatoid arthritis, ama, [[basti]], niruha, rukshasweda

'''Keywords''': Amavata, rheumatoid arthritis, ama, [[basti]], niruha, ruksha sweda

 

 

 

 

 

 

==Causes of the disease==  

 

 

 

 

 

==Causes ([[hetu]]) ==  

*Dietary: Intake of incompatible combinations of foods. [M.Ni 25/01]<ref name=MNi> Madhavakara. Madhava Nidanam (Roga vinischaya). Translated from Sanskrit by K. R. Srikantha Murthy. 8th ed. Varanasi: Chaukhambha orientalia;2007</ref>, irregular dietary habits.

*Dietary: Intake of incompatible combinations of foods. [M.Ni 25/01]<ref name=MNi> Madhavakara. Madhava Nidanam (Roga vinischaya). Translated from Sanskrit by K. R. Srikantha Murthy. 8th ed. Varanasi: Chaukhambha orientalia;2007</ref>, irregular dietary habits.

*Lifestyle: Indulging in strenuousactivities immediately after intake of unctuous/heavy to digest foods. [M.Ni 25/01]<ref name=MNi/>

*Lifestyle: Indulging in strenuous activities immediately after intake of unctuous/heavy to digest foods. [M.Ni 25/01]<ref name=MNi/>

*Psychological: Negative mental states while taking meals. [Cha.Sa. [[Vimana Sthana]] ] Stress is a triggering factor for rheumatoid arthritis.<ref name=Moov>Mooventhan A, Shetty GB. Effect of integrative naturopathy and yoga in a patient with rheumatoid arthritis associated with type 2 diabetes and hypertension. Ancient Sci Life 2017;36:163-6.</ref>

*Psychological: Negative mental states while taking meals. [Cha.Sa. [[Vimana Sthana]] 2/9 ] Stress is a triggering factor for rheumatoid arthritis.<ref name=Moov>Mooventhan A, Shetty GB. Effect of integrative naturopathy and yoga in a patient with rheumatoid arthritis associated with type 2 diabetes and hypertension. Ancient Sci Life 2017;36:163-6.</ref>

*Others: Improper management in pregnancy and post partum period causing aggravation of [[vata]] can lead to amavata.<ref name=Desh>Deshpande SV, Deshpande VS, Potdar SS. Effect of panchakarma and Ayurvedic treatment in postpartum rheumatoid arthritis (amavata): A case study. J Ayurveda Integr Med. 2017 Jan-Mar;8(1):42-44. doi: 10.1016/j.jaim.2016.10.003. Epub 2017 Mar 14. PMID: 28302414; PMCID: PMC5377475. </ref>

*Others: Improper management in pregnancy and post partum period causing aggravation of [[vata]] can lead to amavata.<ref name=Desh>Deshpande SV, Deshpande VS, Potdar SS. Effect of panchakarma and Ayurvedic treatment in postpartum rheumatoid arthritis (amavata): A case study. J Ayurveda Integr Med. 2017 Jan-Mar;8(1):42-44. doi: 10.1016/j.jaim.2016.10.003. Epub 2017 Mar 14. PMID: 28302414; PMCID: PMC5377475. </ref>

Body ache, anorexia, morbid thirst, laziness, heaviness, feverishness, indigestion and edema in body parts are the general features of amavata in its initial phase. [M.Ni 25/6]<ref name=MNi/> When the disease aggravates, it causes severe pain associated with swelling especially in joints of upper and lower limbs and in sacral region. Generalized symptoms like loss of appetite, pain or heaviness in abdomen, excessive micturition, burning sensation, sleep disturbances,  constipation, abdominal distention, vomiting, giddiness are also seen. [M.Ni.25/7-10]<ref name=MNi/>

Body ache, anorexia, morbid thirst, laziness, heaviness, feverishness, indigestion and edema in body parts are the general features of amavata in its initial phase. [M.Ni 25/6]<ref name=MNi/> When the disease aggravates, it causes severe pain associated with swelling especially in joints of upper and lower limbs and in sacral region. Generalized symptoms like loss of appetite, pain or heaviness in abdomen, excessive micturition, burning sensation, sleep disturbances,  constipation, abdominal distention, vomiting, giddiness are also seen. [M.Ni.25/7-10]<ref name=MNi/>

===Dosha specific clinical features===

=== [[Dosha]] specific clinical features===

{| class="wikitable"

{| class="wikitable"

|+ Table 1: Dosha specific clinical features

|+ Table 1: [[Dosha]] specific clinical features

|-

|-

! Dosha  !! Specific clinical features

! [[Dosha]] !! Specific clinical features

|-

|-

| | Vata || Pain   

| | Vata || Pain   

==Pathogenesis==

==Pathogenesis==

Continuous use of incompatible foods and indulging in strenuous activities immediately after unctuous meal leads to indigestion. The channels of transportation and transformation of body fluid (rasavahasrotasa) and marrow (majjavahasrotas) are affected by incompatible foods.  This leads to the formation of ama (metabolic toxins). These toxins are circulated all over the body by vyana vata.

Continuous use of incompatible foods and indulging in strenuous activities immediately after unctuous meal leads to indigestion. The channels of transportation and transformation of body fluid (rasavaha srotasa) and marrow (majjavaha srotas) are affected by incompatible foods.  This leads to the formation of ama (metabolic toxins). These toxins are circulated all over the body by vyana vata.

Physical exercise after taking food is crucial cause of amavata. This is responsible for the movement of [[dosha]] from gastrointestinal tract (koshta) to peripheral tissues (shakha). The circulating toxins accumulate in the joints and affect the associated structures at the joint. This causes clinical features of amavata.<ref name=Mahto>Mahto RR, Dave AR, Shukla VD. A comparative study of RasonaRasnadiGhanavati and SimhanadaGuggulu on Amavata with special reference to Rheumatoid arthritis. Ayu. 2011 Jan;32(1):46-54. doi: 10.4103/0974-8520.85724. PMID: 22131757; PMCID: PMC3215416.</ref>  

Physical exercise after taking food is crucial cause of amavata. This is responsible for the movement of [[dosha]] from gastrointestinal tract (koshta) to peripheral tissues (shakha). The circulating toxins accumulate in the joints and affect the associated structures at the joint. This causes clinical features of amavata.<ref name=Mahto>Mahto RR, Dave AR, Shukla VD. A comparative study of Rasona Rasnadi Ghana vati and SimhanadaGuggulu on Amavata with special reference to Rheumatoid arthritis. Ayu. 2011 Jan;32(1):46-54. doi: 10.4103/0974-8520.85724. PMID: 22131757; PMCID: PMC3215416.</ref>  

In amavata, the intestinal mucosal permeability and peristalsis is impaired. Alteration of bacterial flora of the gut occurs. These factors may result in malabsorption.  This causes indigestion and further vitiation of [[dosha]].<ref name=Basisht>Basisht GK, Singh RH, Chandola H. Management of rheumatoid arthritis (Aamavata) using symbiohealth healthcare system. Ayu. 2012 Oct;33(4):466-74. doi: 10.4103/0974-8520.110513. PMID: 23723661; PMCID: PMC3665188.</ref>

In amavata, the intestinal mucosal permeability and peristalsis is impaired. Alteration of bacterial flora of the gut occurs. These factors may result in malabsorption.  This causes indigestion and further vitiation of [[dosha]].<ref name=Basisht>Basisht GK, Singh RH, Chandola H. Management of rheumatoid arthritis (Aamavata) using symbiohealth healthcare system. Ayu. 2012 Oct;33(4):466-74. doi: 10.4103/0974-8520.110513. PMID: 23723661; PMCID: PMC3665188.</ref>

When the disease is in chronic stage, the quality of tissues is depleted. Thus the defence mechanism is weak. The treatment objective is focused to strengthen the defence mechanism and manage the aggravating factors. The defence strategy includes restoring equilibrium of [[dosha]] and agni, clearing channels by removing ama and thereafter enhancing strength of tissues.

When the disease is in chronic stage, the quality of tissues is depleted. Thus the defence mechanism is weak. The treatment objective is focused to strengthen the defence mechanism and manage the aggravating factors. The defence strategy includes restoring equilibrium of [[dosha]] and agni, clearing channels by removing ama and thereafter enhancing strength of tissues.

'''Symbiohealth approach:'''

'''[[Symbiohealth]] approach:'''

[[File:Simbiohealth.JPG|500px|'''Figure 1: Symbiohealth approach [Source: AYU Journal]'''|thumb]]

[[File:Simbiohealth.JPG|500px|'''Figure 1: Symbiohealth approach [Source: Basisht et.al. AYU Journal]'''|thumb]]

Symbiohealth approach focuses on comprehensive management of disease by including offence and defence strategies of management. A comparative study of the pathogenesis and treatment of RA according to modern medicine and Ayurveda gives many insights helpful in the management of this potentially crippling disease [Figure 1]. It broadens the horizon to win the war against disease. This approach depends upon severity and stage of disease.

[[Symbiohealth]] approach focuses on comprehensive management of disease by including offence and defence strategies of management. A comparative study of the pathogenesis and treatment of RA according to modern medicine and [[Ayurveda]] gives many insights helpful in the management of this potentially crippling disease [Figure 1]. It broadens the horizon to win the war against disease. This approach depends upon severity and stage of disease.

===Preventive strategies===

===Preventive strategies===

Following disease specific wholesome diet and liefestyle can prevent the occurance as well as recurrence of disease. The regimen of pathya-apathya (wholesome and unwholesome regimen) are useful in reducing the drug dependence, dosage and duration of treatment.

Following disease specific wholesome diet and liefestyle can prevent the occurance as well as recurrence of disease. The regimen of pathya-apathya (wholesome and unwholesome regimen) are useful in reducing the drug dependence, dosage and duration of treatment.

==Wholesome foods or Pathya==

====Wholesome foods or Pathya====

#Warm water medicated with Panchkola (Pippali, Pippalimula, Chavya, Chitraka, Shunthi) in small quantity at a time helps in digestion and disintegration of Aama.

#Warm water medicated with Panchkola (Pippali, Pippalimula, Chavya, Chitraka, Shunthi) in small quantity at a time helps in digestion and disintegration of ama.

#Barley, horse gram, kodo millet and the red variety of rice are recommended. These foods are light and easy to digest. Barley kernels and other products made from barley lower inflammatory markers.

#Barley, horse gram, kodo millet and the red variety of rice are recommended. These foods are light and easy to digest. Barley kernels and other products made from barley lower inflammatory markers.

#Green leafy vegetables and fruits contain a variety of polyphenols, bioflavonoids, catechins, carotenoids, vitamin C, riboflavin, vitamin E, and low molecular weight compounds. These constituents have antioxidant, fibrinolytic and anti-inflammatory characteristics. Vegetables preferably with bitter taste like bitter melon (Memordica charantia), Neem (Azadirachta indica), Patola or luffa, Gokharu (Tribulus terrestris) are recommended.

#Green leafy vegetables and fruits contain a variety of polyphenols, bioflavonoids, catechins, carotenoids, vitamin C, riboflavin, vitamin E, and low molecular weight compounds. These constituents have antioxidant, fibrinolytic and anti-inflammatory characteristics. Vegetables preferably with bitter taste like bitter melon (Memordica charantia), Neem (Azadirachta indica), Patola or luffa, Gokshura (Tribulus terrestris) are recommended.

#Spices like ginger, turmeric and garlic help to add flavor to these dishes and also have antimicrobial, anti-inflammatory and analgesic properties besides their Agni promoting impact.

#Spices like ginger, turmeric and garlic help to add flavor to these dishes and also have antimicrobial, anti-inflammatory and analgesic properties besides their Agni promoting impact.

#Wine-old wine, Asava and Arishta.

#Wine-old wine, Asava and Arishta.

#Meat of Laav Pakshi-Jungle bush quail (Perdicula asiatica) prepared with traditional buttermilk.<ref>Sharma H, Clark C. Diet and digestion. Ayurvedic Healing. 2 nd ed. Philadelphia: Singing Dragon; 2012. p. 71-93. </ref>, <ref>Govinda Das, Bhaishajya Ratnavali, Amavata Chikitsa, 29, Commentary by Ambika Datt Shastri. Reprint ed. Varanasi: Chaukhambha Prakashan; 2012. p. 613-32.</ref>

#Meat of Laav Pakshi-Jungle bush quail (Perdicula asiatica) prepared with traditional buttermilk.<ref>Sharma H, Clark C. Diet and digestion. Ayurvedic Healing. 2 nd ed. Philadelphia: Singing Dragon; 2012. p. 71-93. </ref>, <ref>Govinda Das, Bhaishajya Ratnavali, Amavata Chikitsa, 29, Commentary by Ambika Datt Shastri. Reprint ed. Varanasi: Chaukhambha Prakashan; 2012. p. 613-32.</ref>

==Wholesome lifestyle==

====Wholesome lifestyle====

#Following proper daily regimen ([[dinacharya]]) and night regimen (ratricharya)  

#Following proper daily regimen ([[dinacharya]]) and night regimen (ratricharya)  

#Meditation

#Meditation

==Foods to avoid or Apathya==

====Foods to avoid or Apathya====

The majority of allergens come from dairy and animal products, which cause an increased production of pro-inflammatory prostaglandins.

The majority of allergens come from dairy and animal products, which cause an increased production of pro-inflammatory prostaglandins.

#Fish and sea foods.  

#Fish and sea foods.  

==Unwholesome lifestyle==

====Unwholesome lifestyle====

   

   

#Strenous physical activities after taking heavy meals  

#Strenous physical activities after taking heavy meals  

#Daytime sleep after meals.

#Daytime sleep after meals.

==Principles of management==

===Principles of management===

The principles of management of amavata are focused on following:  

The principles of management of amavata are focused on following:  

[Chakradatta Amavatachikitsa]<ref name=Chakradatta>Chakrapanidatta, Cakradatta (Chikitsasangraha). Edited by Priya Vrat Sharma. 3rd ed. Varanasi: Chaukhambha publishers; 2002</ref>

[Chakradatta Amavatachikitsa]<ref name=Chakradatta>Chakrapanidatta, Cakradatta (Chikitsasangraha). Edited by Priya Vrat Sharma. 3rd ed. Varanasi: Chaukhambha publishers; 2002</ref>

==Currently used important herbs==

====Currently used important herbs====

   

   

'''Piper longum (pippali):''' In a study 73 clinically diagnosed Rheumatoid arthritis patients were administered powder of Piper longum (pippali) in increasing dose pattern. Initially, on first day 1 gm of Piper longum (pippali) powder twice a day with honey was given. The dose was increased daily by 1gm upto 5gm twice a day. The 5gm dose (maximum dose) was maintained for 5 days.  Then the dose was tapered by 1 gm daily upto 1gm twice a day. After this, mild purgation with castor oil was given. The pain, stiffness, swelling and movement restriction in joints decreased significantly by 50.56%, 48.57%, 53.22% and 46.43% respectively. A significant reduction in ESR was also reported after this treatment. Pippali leads to digestion of accumulated toxic metabolic toxins (ama) by its stimulating ([[deepana]]) and appetizer activity.  It also has rejuvenating ([[rasayana]]) and immunomodulating actions.<ref name=Soni>Soni A, Patel K, Gupta SN. Clinical evaluation of VardhamanaPippaliRasayana in the management of Amavata (Rheumatoid Arthritis). Ayu. 2011 Apr;32(2):177-80. doi: 10.4103/0974-8520.92555. PMID: 22408298; PMCID: PMC3296336.</ref>

'''Piper longum (pippali):''' In a study 73 clinically diagnosed Rheumatoid arthritis patients were administered powder of Piper longum (pippali) in increasing dose pattern. Initially, on first day 1 gm of Piper longum (pippali) powder twice a day with honey was given. The dose was increased daily by 1gm upto 5gm twice a day. The 5gm dose (maximum dose) was maintained for 5 days.  Then the dose was tapered by 1 gm daily upto 1gm twice a day. After this, mild purgation with castor oil was given. The pain, stiffness, swelling and movement restriction in joints decreased significantly by 50.56%, 48.57%, 53.22% and 46.43% respectively. A significant reduction in ESR was also reported after this treatment. Pippali leads to digestion of accumulated toxic metabolic toxins (ama) by its stimulating ([[deepana]]) and appetizer activity.  It also has rejuvenating ([[rasayana]]) and immunomodulating actions.<ref name=Soni>Soni A, Patel K, Gupta SN. Clinical evaluation of VardhamanaPippaliRasayana in the management of Amavata (Rheumatoid Arthritis). Ayu. 2011 Apr;32(2):177-80. doi: 10.4103/0974-8520.92555. PMID: 22408298; PMCID: PMC3296336.</ref>

'''Asteracantha longifolia (kokilaksha)''' is found to effective in treating rheumatoid arthritis. Its anti-inflammatory property is already reported. The higher protein content may help to enhance the immunity. It may also help to destruct the immune aggregate, which is one of the basic causes for the disease.<ref name=Thanka>Thankamma A. Rheumatoid arthritis and astercantha longifolia. Anc Sci Life. 1999 Jan;18(3-4):247-9. PMID: 22556897; PMCID: PMC3336470.</ref>  

'''Asteracantha longifolia (kokilaksha)''' is found to effective in treating rheumatoid arthritis. Its anti-inflammatory property is already reported. The higher protein content may help to enhance the immunity. It may also help to destruct the immune aggregate, which is one of the basic causes for the disease.<ref name=Thanka>Thankamma A. Rheumatoid arthritis and astercantha longifolia. Anc Sci Life. 1999 Jan;18(3-4):247-9. PMID: 22556897; PMCID: PMC3336470.</ref>  

Tinospora cordifolia (guduchi), Zingiber officinale (shunthi), Semecarpus anacardium (bhallataka) are also usedbased on clinical conditions. [Chikitsapradeepa Amavataroga]<ref name=Pradeep>Gokhale B.V. Amavataroga.In: Chikitsapradeep.Pune:Dhanwantary Pratishthan;1989</ref> Shunthi possess active principles gingerol, dehydrozingerone and gingerdione. These are potent prostaglandin inhibitors. Thus, it attains anti – arthritic effect. Glycosides present in Guduchi acts like NSAIDs thus producing anti – arthritic effect.<ref name=Lekur>Lekurwale PS, Pandey K, Yadaiah P. Management of Amavata with 'Amrita Ghrita': A clinical study. Ayu. 2010 Oct;31(4):430-5. doi: 10.4103/0974-8520.82033. PMID: 22048534; PMCID: PMC3202259. </ref>

Tinospora cordifolia (guduchi), Zingiber officinale (shunthi), Semecarpus anacardium (bhallataka) are also used based on clinical conditions. [Chikitsapradeepa Amavataroga]<ref name=Pradeep>Gokhale B.V. Amavataroga.In: Chikitsapradeep.Pune:Dhanwantary Pratishthan;1989</ref> Shunthi possess active principles gingerol, dehydrozingerone and gingerdione. These are potent prostaglandin inhibitors. Thus, it attains anti – arthritic effect. Glycosides present in Guduchi acts like NSAIDs thus producing anti – arthritic effect.<ref name=Lekur>Lekurwale PS, Pandey K, Yadaiah P. Management of Amavata with 'Amrita Ghrita': A clinical study. Ayu. 2010 Oct;31(4):430-5. doi: 10.4103/0974-8520.82033. PMID: 22048534; PMCID: PMC3202259. </ref>

==Currently used important herbal formulations==

====Currently used important herbal formulations====

If the condition is associated with fever, Amrutottaram kwatha, Amritarishta and Chitrakasava are used.<ref name=Edava>Edavalath M. Ankylosing spondylitis. J Ayurveda Integr Med. 2010 Jul;1(3):211-4. doi: 10.4103/0975-9476.72619. PMID: 21547050; PMCID: PMC3087367. </ref>

If the condition is associated with fever, Amrutottaram kwatha, Amritarishta and Chitrakasava are used.<ref name=Edava>Edavalath M. Ankylosing spondylitis. J Ayurveda Integr Med. 2010 Jul;1(3):211-4. doi: 10.4103/0975-9476.72619. PMID: 21547050; PMCID: PMC3087367. </ref>

'''Decoctions:'''

'''Decoctions:'''

MahaRasnadikwatha, Ashwagandharistha, RasnaPanchakKwatha, RasnaSaptakaKwatha, Dashamoolarishta, and Amritarishta.

Maharasnadi kwatha, Ashwagandharistha, Rasnapanchak Kwatha, Rasnasaptaka Kwatha, Dashamoolarishta, and Amritarishta.

'''Herbal powder mixtures/Churnas:'''

'''Herbal powder mixtures/Churnas:'''

Bhallataka Avaleha,  Gorakha Avaleha.

Bhallataka Avaleha,  Gorakha Avaleha.

Various preparations of Bhallataka can be used in Aamavata. However, these preparations shall be used with precaution in case of dominance of [[pitta dosha]].

Various preparations of Bhallataka can be used in Amavata. However, these preparations shall be used with precaution in case of dominance of [[pitta dosha]].

==Research on ayurvedic formulations==

=====Research on ayurvedic formulations=====

   

   

'''Rasonarasnadighanavati, Simhanadaguggulu:''' In a study, 101 amavata patients were divided into two groups. In one group Rasonarasnadighanavati (250mg) was administered in the dosage of 2 tablets three times a day with hot water for 3 months. In addition to this,rasonarasnadilepa was applied at the affected joints twice a day for three months. In another group, simhanadaguggulu was administered in the dose of 2 tablets thrice a day with hot water for 3 months. General signs and symptoms of amavata were reduced in both the groups. Rasonarasnadighanavati showed better pain reliving action. Simhanadaguggulu showed better reduction in swelling of joints. Most of the drugs in rasonarasnadighanavati possess pungent and bitter taste, hot potency, [[rasayana]] and ama digesting properties. This helps to break the disease pathogenesis. Moreover, it has immunomodulatory action too. Simhanadaguggulu possess [[vata]]-[[kapha]] pacifying action and stimulates digestive capacity. It has antioxidant properties also.<ref name=Mahto/> Bitter and pungent taste, hot potency, dry and light properties of the drugs help to break the pathogenesis. All these properties are antagonistic to ama and [[vata]]. Kindling the digestive capacity helps to correct the ama status and there by removes the obstruction in the channels.<ref name=Pandey>Pandey SA, Joshi NP, Pandya DM. Clinical efficacy of Shiva Guggulu and SimhanadaGuggulu in Amavata (Rheumatoid Arthritis). Ayu. 2012 Apr;33(2):247-54. doi: 10.4103/0974-8520.105246. PMID: 23559798; PMCID: PMC3611626.</ref>

'''Rasonarasnadi ghanavati, Simhanada guggulu:''' In a study, 101 amavata patients were divided into two groups. In one group Rasonarasnadi ghanavati (250mg) was administered in the dosage of 2 tablets three times a day with hot water for 3 months. In addition to this, rasonarasnadi lepa was applied at the affected joints twice a day for three months. In another group, simhanada guggulu was administered in the dose of 2 tablets thrice a day with hot water for 3 months. General signs and symptoms of amavata were reduced in both the groups. Rasonarasnadi ghana vati showed better pain reliving action. Simhanada guggulu showed better reduction in swelling of joints. Most of the drugs in rasonarasnadi ghana vati possess pungent and bitter taste, hot potency, [[rasayana]] and ama digesting properties. This helps to break the disease pathogenesis. Moreover, it has immunomodulatory action too. Simhanada guggulu possess [[vata]]-[[kapha]] pacifying action and stimulates digestive capacity. It has antioxidant properties also.<ref name=Mahto/> Bitter and pungent taste, hot potency, dry and light properties of the drugs help to break the pathogenesis. All these properties are antagonistic to ama and [[vata]]. Kindling the digestive capacity helps to correct the ama status and there by removes the obstruction in the channels.<ref name=Pandey>Pandey SA, Joshi NP, Pandya DM. Clinical efficacy of Shiva Guggulu and Simhanad aGuggulu in Amavata (Rheumatoid Arthritis). Ayu. 2012 Apr;33(2):247-54. doi: 10.4103/0974-8520.105246. PMID: 23559798; PMCID: PMC3611626.</ref>

In an experimental study, rheumatoid arthritis was induced in male wister rats. A formulation containing Commifora mukul, Strychnosnux vomica, Boswellia sereta, Maharasnadi kwatha and Suvarna bhasma was administered. It was found effective in reducing the signs and symptoms of Rheumatoid arthritis. These drugs have proven anti-inflammatory activity. The active principles like guggulsterones, boswellic acid, brucine can inhibit inflammatory mediator over production.<ref name=PatelSS>Patel SS, Shah PV. Evaluation of anti-inflammatory potential of the multidrug herbomineral formulation in male Wistar rats against rheumatoid arthritis. J Ayurveda Integr Med 2013;4:86-93.</ref>

In an experimental study, rheumatoid arthritis was induced in male wister rats. A formulation containing Commifora mukul, Strychnosnux vomica, Boswellia sereta, Maharasnadi kwatha and Suvarna bhasma was administered. It was found effective in reducing the signs and symptoms of Rheumatoid arthritis. These drugs have proven anti-inflammatory activity. The active principles like guggulsterones, boswellic acid, brucine can inhibit inflammatory mediator over production.<ref name=PatelSS>Patel SS, Shah PV. Evaluation of anti-inflammatory potential of the multidrug herbomineral formulation in male Wistar rats against rheumatoid arthritis. J Ayurveda Integr Med 2013;4:86-93.</ref>

'''Vatari guggulu:''' A study on 58 patients diagnosed with amavata reported vatari guggulu is effective in reducing the symptoms such as pain, swelling, stiffness and tenderness in joints. There was statistically significant reduction in RA factor,too. However, the study showed the efficacy of drug decreases with increase in the chronicity of disease.<ref name=Maraga/> The general symptoms like bodyache, heaviness, anorexia were significantly reduced significantly by vatari guggulu.<ref name=Khagram>Khagram R, Mehta CS, Shukla VD, Dave AR. Clinical effect of Matra Basti and VatariGuggulu in the management of Amavata (rheumatoid arthritis). Ayu. 2010 Jul;31(3):343-50. doi: 10.4103/0974-8520.77167. PMID: 22131737; PMCID: PMC3221069.</ref>

'''Vatari guggulu:''' A study on 58 patients diagnosed with amavata reported vatari guggulu is effective in reducing the symptoms such as pain, swelling, stiffness and tenderness in joints. There was statistically significant reduction in RA factor,too. However, the study showed the efficacy of drug decreases with increase in the chronicity of disease.<ref name=Maraga/> The general symptoms like bodyache, heaviness, anorexia were significantly reduced significantly by vatari guggulu.<ref name=Khagram>Khagram R, Mehta CS, Shukla VD, Dave AR. Clinical effect of Matra Basti and Vatari Guggulu in the management of Amavata (rheumatoid arthritis). Ayu. 2010 Jul;31(3):343-50. doi: 10.4103/0974-8520.77167. PMID: 22131737; PMCID: PMC3221069.</ref>

'''Alambushadi Ghana vati:''' Alambushadi ghana vati is observed effective in reducing the pain, stiffness, swelling and tenderness associated with amavata.  There was 60% reduction in anorexia and more than 66% reduction in fever.<ref name=Sasane>Sasane P, Saroj UR, Joshi RK. Clinical evaluation of efficacy of Alambushadi Ghana Vatiand Vaitarana Basti in the management of Amavatawith special reference to rheumatoid arthritis. Ayu 2016;37:105-12.</ref>

'''Alambushadi Ghana vati:''' Alambushadi ghana vati is observed effective in reducing the pain, stiffness, swelling and tenderness associated with amavata.  There was 60% reduction in anorexia and more than 66% reduction in fever.<ref name=Sasane>Sasane P, Saroj UR, Joshi RK. Clinical evaluation of efficacy of Alambushadi Ghana Vatiand Vaitarana Basti in the management of Amavatawith special reference to rheumatoid arthritis. Ayu 2016;37:105-12.</ref>

'''Amrita ghrita:''' A study conducted on 28 patients of amavata patients reported that administration of amrita ghrita is helpful in managing the signs and symptoms of amavata. There was 43% reduction in ESR, 51% reduction in ASO titer and CRP reduced by 63% after 45 days of administration of 15 gm of amrita ghrita with milk.<ref name=Lekur/>

'''Amrita ghrita:''' A study conducted on 28 patients of amavata patients reported that administration of amrita ghrita is helpful in managing the signs and symptoms of amavata. There was 43% reduction in ESR, 51% reduction in ASO titer and CRP reduced by 63% after 45 days of administration of 15 gm of amrita ghrita with milk.<ref name=Lekur/>

Rasnerandadi kwatha<ref name=Edava/>,Rasnasaptaka kwatha, Rasnapanchaka kwatha, Rasnadashamula kwatha,  Yogaraja guggulu, Vaishwanara churna are also mentioned for the treatment of amavata. [Chakradatta]<ref name=Chakradatta/>

Rasna erandadi kwatha<ref name=Edava/>,Rasnasaptaka kwatha, Rasnapanchaka kwatha, Rasnadashamula kwatha,  Yogaraja guggulu, Vaishwanara churna are also mentioned for the treatment of amavata. [Chakradatta]<ref name=Chakradatta/>

==Currently used important herbo-mineral formulations==  

====Currently used important herbo-mineral formulations====  

If associated with fever: Amavatari rasa, Vettumaran gulika<ref name=Edava/>

If associated with fever: Amavatari rasa, Vettumaran gulika<ref name=Edava/>

==[[Panchakarma]] procedures with safety precautions==

====[[Panchakarma]] procedures with safety precautions====

===Therapeutic enema ([[basti]])===

=====Therapeutic enema ([[basti]])=====

'''Panchamuladi basti:''' In a study, 12 patients having rheumatoid arthritis (amavata) were managed with Ayurvedic treatment protocol. It included initial 3 days of fasting followed by 3 days of [[deepana]] and [[pachana]] therapy with 10gm trikatu powder 3 times a day with hot water after food. This is followed by 15 days of therapeutic enema ([[basti]]) schedule. Here the schedule of [[basti]] includes 2 medicated unctuous enema (anuvasana basti) initially, 5 decoction enema (niruha basti) and 5 medicated unctuous enema (anuvasana basti) intermittently and 5 medicated unctuous enema (anuvasana basti) in the end. Panchamuladi basti is used as niruha and panchamuladi taila is used for anuvasana. There were highly significant results in disease specific symptoms like pain in joints, swelling, stiffness, warmth and tenderness in joints. Highly significant results were also seen in general symptoms like heaviness (gaurava), malaise (angamarda), indigestion (apaka), edema (angashunata) and laziness (alasya). Total 70% reduction in thirst and a complete recovery from feverishness were also reported. The alkaline nature of this [[basti]] cures the ama along with it controls the [[vata dosha]] also. Unctuous enema also helps to control [[vata dosha]] by acting directly over the main site of [[vata]] that is colon (pakwashaya).<ref name=Baria/>

'''Panchamuladi basti:''' In a study, 12 patients having rheumatoid arthritis (amavata) were managed with Ayurvedic treatment protocol. It included initial 3 days of fasting followed by 3 days of [[deepana]] and [[pachana]] therapy with 10gm trikatu powder 3 times a day with hot water after food. This is followed by 15 days of therapeutic enema ([[basti]]) schedule. Here the schedule of [[basti]] includes 2 medicated unctuous enema (anuvasana basti) initially, 5 decoction enema (niruha basti) and 5 medicated unctuous enema (anuvasana basti) intermittently and 5 medicated unctuous enema (anuvasana basti) in the end. Panchamuladi basti is used as niruha and panchamuladi taila is used for anuvasana. There were highly significant results in disease specific symptoms like pain in joints, swelling, stiffness, warmth and tenderness in joints. Highly significant results were also seen in general symptoms like heaviness (gaurava), malaise (angamarda), indigestion (apaka), edema (angashunata) and laziness (alasya). Total 70% reduction in thirst and a complete recovery from feverishness were also reported. The alkaline nature of this [[basti]] cures the ama along with it controls the [[vata dosha]] also. Unctuous enema also helps to control [[vata dosha]] by acting directly over the main site of [[vata]] that is colon (pakwashaya).<ref name=Baria/>

A diagnosed case of Ankylosing spondylitis was treated according to the treatment principles of amavata. A 21 years old male patient complaining of severe pain in low back and both knee joints with morning stiffness for more than an hour. Intermittent fever with chills and headache were also present. Reduced appetite and constipation was associated complaints.  The investigations like ESR was 140 mm/hr, MRI of lumbar spine suggested bilateral sacrolitis and Human leukocyte antigen (HLA B27) was positive. The diagnosis of amavata was made based on clinical features. Initially to reduce the fever, Amrutotaram kwata, Amavatari rasa and Amritarishta were given. Since the fever persists after two weeks Amavatari rasa and Amritarishta were replaced with Vettumaran gulika and Chitrakasava. After the subsidence of fever lepa was applied over the painful areas with Kottamchukkadi churna and dhanyamla. Swelling and pain in joint subsides but since the patient develops skin rashes kottamchukkadi was replace with Grihadumadi churna. After 1 month the patient was able to walk without support and the fever subsided completely. Then the internal medications were revised to Indukantam kwatha, Marmagulika and Shaddharana churna. Fomentation with bolus of Kolakulathadi powder was also applied for 10 days. Therapeutic purgation ([[virechana]]) with Gandharvaeranda was administered on alternate days. After fomentation, pain in low back  and other joints was reduced. Morning stiffness was still present. Therapeutic enema ([[basti]]) was administered in kala basti pattern. It included six balaguduchyadi niruha basti and 9 anuvasana basti. Significant improvement in pain and stiffness was noticed after the [[basti]]. Niruha basti is the main treatment for rheumatic disorders. After that as pacifying therapy Rasna-erandadi kwata, Simhanada guggulu and Gandharva-eranda was administered.  His ESR was reduced to 5mm/hr after 3 months of treatment.<ref name=Edava/>

A diagnosed case of Ankylosing spondylitis was treated according to the treatment principles of amavata. A 21 years old male patient complaining of severe pain in low back and both knee joints with morning stiffness for more than an hour. Intermittent fever with chills and headache were also present. Reduced appetite and constipation was associated complaints.  The investigations like ESR was 140 mm/hr, MRI of lumbar spine suggested bilateral sacrolitis and Human leukocyte antigen (HLA B27) was positive. The diagnosis of amavata was made based on clinical features. Initially to reduce the fever, Amrutotaram kwata, Amavatari rasa and Amritarishta were given. Since the fever persists after two weeks Amavatari rasa and Amritarishta were replaced with Vettumaran gulika and Chitrakasava. After the subsidence of fever lepa was applied over the painful areas with Kottamchukkadi churna and dhanyamla. Swelling and pain in joint subsides but since the patient develops skin rashes kottamchukkadi was replace with Grihadumadi churna. After 1 month the patient was able to walk without support and the fever subsided completely. Then the internal medications were revised to Indukantam kwatha, Marmagulika and Shaddharana churna. Fomentation with bolus of Kolakulathadi powder was also applied for 10 days. Therapeutic purgation ([[virechana]]) with Gandharvaeranda was administered on alternate days. After fomentation, pain in low back  and other joints was reduced. Morning stiffness was still present. Therapeutic enema ([[basti]]) was administered in kala basti pattern. It included six balaguduchyadi niruha basti and 9 anuvasana basti. Significant improvement in pain and stiffness was noticed after the [[basti]]. Niruha basti is the main treatment for rheumatic disorders. After that as pacifying therapy Rasna-erandadi kwata, Simhanada guggulu and Gandharva-eranda was administered.  His ESR was reduced to 5mm/hr after 3 months of treatment.<ref name=Edava/>

A 27 year old female patient developed amavata, 1 month after her delivery. She complaints of pain and swelling in bilateral corpo-phalangel joints, both knees and ankles along with morning stiffness, anorexia and bodyache for six months. Tenderness along with raised body temperature and stiffness was present in the affected joints. Her RA factor and Anti CCP antibody were positive. RA factor 160 IU/ml and anti CCP more than 200 units/ml. Patient was treated with oral medications and [[panchakarma]] treatments. During the entire course of treatment, she continued breast feeding and the baby showed normal growth and development. The treatment for four months includes oral administration of Simhanada guggulu, Pratapalankeshwara rasa, Dashamoolakatutraya kashaya, combination of Swarnabhupati rasa, mahavatavidhvansa rasa, Tapyadiloha along with Smilax china (chopachini), Zinziber officinale (shunthi) and Tinospora cordifolia (guduchi).  [[Panchakarma]] treatment includes whole body massage with Vishagharbhataila, fomentation in wooden chamber (bashpa sweda) and therapeutic enema ([[basti]]). The [[basti]] schedule consists of total 16 basti, including 10 unctuous enema and 6 decoction enema. For unctuous enema, 60 ml Pippalyadi taila, 10ml honey and 3gm rock salt were used. For decoction enema, 500ml decoction is prepared with dashamoola etc. drugs with paste (100ml) of tamarind and jaggery, 100ml cow’s urine, 40 ml Pippalyaditaila, 30ml honey and 5 gm rock salt. After the [[panchakarma]] treatment patient continued the oral medications and application of Vishagarbha taila for three months. There was marked reduction in bodyache and anorexia after the first 15 days of treatment but morning stiffness persists. After 1 month of [[panchakarma]] treatment, morning stiffness reduced. After 75 days of treatment, there was considerable reduction in tenderness and edema in joints and complete subsidence of anorexia and bodyache. After 4 months of treatment, the patient become completely symptom free and RA factor came to normal level. Pratapalankeshwara rasa is beneficial in reducing [[vata]] especially in postpartum stage.  Dasamoolakatutraya pacifies [[vata]], improves digestion, nourishes blood and is having the ability to reduce the pain in joints. Swarnabhupati rasa acts on [[vata]][[kapha]] disorders related with musculoskeletal system. Tapyadiloha improves blood, Chopachini, shunthi and guduchi digests the ama and clears the obstruction in the path of [[vata]].<ref name=Desh/>

A 27 year old female patient developed amavata, 1 month after her delivery. She complaints of pain and swelling in bilateral corpo-phalangel joints, both knees and ankles along with morning stiffness, anorexia and bodyache for six months. Tenderness along with raised body temperature and stiffness was present in the affected joints. Her RA factor and Anti CCP antibody were positive. RA factor 160 IU/ml and anti CCP more than 200 units/ml. Patient was treated with oral medications and [[panchakarma]] treatments. During the entire course of treatment, she continued breast feeding and the baby showed normal growth and development. The treatment for four months includes oral administration of Simhanada guggulu, Pratapalankeshwara rasa, Dashamoolakatutraya kashaya, combination of Swarnabhupati rasa, mahavatavidhvansa rasa, Tapyadiloha along with Smilax china (chopachini), Zinziber officinale (shunthi) and Tinospora cordifolia (guduchi).  [[Panchakarma]] treatment includes whole body massage with Vishagharbhataila, fomentation in wooden chamber (bashpa sweda) and therapeutic enema ([[basti]]). The [[basti]] schedule consists of total 16 basti, including 10 unctuous enema and 6 decoction enema. For unctuous enema, 60 ml Pippalyadi taila, 10ml honey and 3gm rock salt were used. For decoction enema, 500ml decoction is prepared with dashamoola etc. drugs with paste (100ml) of tamarind and jaggery, 100ml cow’s urine, 40 ml Pippalyadi taila, 30ml honey and 5 gm rock salt. After the [[panchakarma]] treatment patient continued the oral medications and application of Vishagarbha taila for three months. There was marked reduction in bodyache and anorexia after the first 15 days of treatment but morning stiffness persists. After 1 month of [[panchakarma]] treatment, morning stiffness reduced. After 75 days of treatment, there was considerable reduction in tenderness and edema in joints and complete subsidence of anorexia and bodyache. After 4 months of treatment, the patient become completely symptom free and RA factor came to normal level. Pratapalankeshwara rasa is beneficial in reducing [[vata]] especially in postpartum stage.  Dasamoola katutraya pacifies [[vata]], improves digestion, nourishes blood and is having the ability to reduce the pain in joints. Swarnabhupati rasa acts on [[vata]][[kapha]] disorders related with musculoskeletal system. Tapyadiloha improves blood, Chopachini, shunthi and guduchi digests the ama and clears the obstruction in the path of [[vata]].<ref name=Desh/>

A 54 yearold woman diagnosed as Rheumatoid arthritis associated with hypertension and type 2 diabetes was reported to be treated through an integrative approach which includes Naturopathy, Yoga and Acupuncture. The patient complains of moderate to severe pain, swelling and morning stiffness in multiple joints especially over bilateral small joints, elbow, shoulder, knees and hip. Hydrotherapy, mud therapy, massage therapy, yoga therapy and acupuncture were given for 10 days as a supportive treatment. There was improvement in pain, ESR, FBS, PPBS counts. These therapies are reported to have analgesic action. Mud therapy may reduce the inflammation. Sulphur minerals present in mud might get absorbed through skin results in analgesic effect. The action over thermo and mechano receptors through hydro therapy may block nociceptors there by reducing pain. Muscle relaxation achieved through massage might be the cause for pain reduction through massage therapy. Pain reduction through acupuncture might be through modulation of nor adrenaline and serotonin signalling system.  Formation of endogenous opioids, somatostatin and other neurotrophins may block the passage of pain signals. Yoga reduces stress and has action over musculo- skeletal system. Stress itself can act as triggering factor for rheumatoid arthritis.<ref name=Moov/>

A 54 year old woman diagnosed as Rheumatoid arthritis associated with hypertension and type 2 diabetes was reported to be treated through an integrative approach which includes Naturopathy, Yoga and Acupuncture. The patient complains of moderate to severe pain, swelling and morning stiffness in multiple joints especially over bilateral small joints, elbow, shoulder, knees and hip. Hydrotherapy, mud therapy, massage therapy, yoga therapy and acupuncture were given for 10 days as a supportive treatment. There was improvement in pain, ESR, FBS, PPBS counts. These therapies are reported to have analgesic action. Mud therapy may reduce the inflammation. Sulphur minerals present in mud might get absorbed through skin results in analgesic effect. The action over thermo and mechano receptors through hydro therapy may block nociceptors there by reducing pain. Muscle relaxation achieved through massage might be the cause for pain reduction through massage therapy. Pain reduction through acupuncture might be through modulation of nor adrenaline and serotonin signalling system.  Formation of endogenous opioids, somatostatin and other neurotrophins may block the passage of pain signals. Yoga reduces stress and has action over musculo- skeletal system. Stress itself can act as triggering factor for rheumatoid arthritis.<ref name=Moov/>

A 45 year old female with multiple joint pain associated with swelling, morning stiffness, movement restricted and loss of appetite. She was diagnosed with amavata. Treatment includes [[deepana]]-[[pachana]] with amapachanavati for 1 week. It was followed by internal administration of cow’s ghee in escalating dose pattern for 5 days. Fomentation was done for the next 3 days which was followed by therapeutic purgation ([[virechana]]) with Trivritaavaleha (100gm) and castor oil (20ml). After completion of [[virechana]] and diet protocol (samsarjana krama), the 40% reduction in pain and stiffness of joints. RA factor was reduced from 94 IU/ml to 50 IU/ml after [[virechana]]. The patient was put on specific diet pattern after [[virechana]]. After 3 months of treatment, there was significant reduction in all signs and symptoms of amavata. IgE was reduced from 680 kU/L to 53.7 kU/L.<ref name=Gupta>Gupta SK, Thakar AB, Dudhamal TS, Nema A. Management of Amavata(rheumatoid arthritis) with diet and Virechanakarma. Ayu 2015;36:413-5. </ref>

A 45 year old female with multiple joint pain associated with swelling, morning stiffness, movement restricted and loss of appetite. She was diagnosed with amavata. Treatment includes [[deepana]]-[[pachana]] with amapachanavati for 1 week. It was followed by internal administration of cow’s ghee in escalating dose pattern for 5 days. Fomentation was done for the next 3 days which was followed by therapeutic purgation ([[virechana]]) with Trivritaavaleha (100gm) and castor oil (20ml). After completion of [[virechana]] and diet protocol (samsarjana krama), there was 40% reduction in pain and stiffness of joints. RA factor was reduced from 94 IU/ml to 50 IU/ml after [[virechana]]. The patient was put on specific diet pattern after [[virechana]]. After 3 months of treatment, there was significant reduction in all signs and symptoms of amavata. IgE was reduced from 680 kU/L to 53.7 kU/L.<ref name=Gupta>Gupta SK, Thakar AB, Dudhamal TS, Nema A. Management of Amavata(rheumatoid arthritis) with diet and Virechanakarma. Ayu 2015;36:413-5. </ref>

==Research updates==

===Research updates===

   

   

A double dummy randomized pilot trail was conducted to compare classic [[Ayurveda]], methotrexate (MTX), and their combination in rheumatoid arthritis (RA) for 36 weeks. Forty-three seropositive RA patients were diagnosed on criteria by American College of Rheumatology (ACR) criteria. The treatment groups included  MTX plus Ayurvedic placebo (n = 14), Ayurveda plus MTX placebo (n = 12), or Ayurveda plus MTX (n = 17). It was observed that all three treatments were approximately equivalent in efficacy. Adverse events were numerically fewer in the [[Ayurveda]]-only group. <ref>Furst, Daniel E. MD*; Venkatraman, Manorama M. PhD†; McGann, Mary MPH, MSW**; Manohar, P. Ram MD (Ayurveda)‡; Booth-LaForce, Cathryn PhD†; Sarin, Reshmi MD (Ayurveda)‡; Sekar, P.G. MBBS**✠; Raveendran, K.G. BAM&S‡; Mahapatra, Anita MD§; Gopinath, Jidesh BS‡; Kumar, P.R. Krishna BAM&S‡ Double-Blind, Randomized, Controlled, Pilot Study Comparing Classic Ayurvedic Medicine, Methotrexate, and Their Combination in Rheumatoid Arthritis, Journal of Clinical Rheumatology: June 2011 - Volume 17 - Issue 4 - p 185-192 doi: 10.1097/RHU.0b013e31821c0310</ref>

A double dummy randomized pilot trail was conducted to compare classic [[Ayurveda]], methotrexate (MTX), and their combination in rheumatoid arthritis (RA) for 36 weeks. Forty-three seropositive RA patients were diagnosed on criteria by American College of Rheumatology (ACR) criteria. The treatment groups included  MTX plus Ayurvedic placebo (n = 14), Ayurveda plus MTX placebo (n = 12), or Ayurveda plus MTX (n = 17). It was observed that all three treatments were approximately equivalent in efficacy. Adverse events were numerically fewer in the [[Ayurveda]]-only group. <ref>Furst, Daniel E. MD*; Venkatraman, Manorama M. PhD†; McGann, Mary MPH, MSW**; Manohar, P. Ram MD (Ayurveda)‡; Booth-LaForce, Cathryn PhD†; Sarin, Reshmi MD (Ayurveda)‡; Sekar, P.G. MBBS**✠; Raveendran, K.G. BAM&S‡; Mahapatra, Anita MD§; Gopinath, Jidesh BS‡; Kumar, P.R. Krishna BAM&S‡ Double-Blind, Randomized, Controlled, Pilot Study Comparing Classic Ayurvedic Medicine, Methotrexate, and Their Combination in Rheumatoid Arthritis, Journal of Clinical Rheumatology: June 2011 - Volume 17 - Issue 4 - p 185-192 doi: 10.1097/RHU.0b013e31821c0310</ref>

==References==

==References==

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