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A 37-year-old male patient is a K/C/O Type 2 Diabetes mellitus since 3 years. He presented with excessive tiredness, weight loss, polyuria and polydipsia, and pain in the soles of the feet for 8 months. He also experienced stress, anxiety, overthinking and memory loss. He had consulted an allopathic doctor at the onset of symptoms in 2019. The biomedical diagnosis was DM type 2 based on the HbA1c value. He tried Insulin for 3 months. Stopped Insulin and then started taking anti-diabetic medications. But in spite of taking medicines, the blood sugar control was very poor and the symptoms persisted. So he consulted Dr Partap Chauhan for better management of the condition. The ayurvedic diagnosis was Prameha. The line of treatment followed was vata-pitta and vata-kapha shamana, medhya, rasayana and sroto shodhana. With 5 months of ayurvedic treatment along with diet and lifestyle modification, he was able to reduce the dosage of his concomitant medicine. The HbA1c reduced to 7.4 from 10.9 recorded at baseline, indicating good blood sugar control. He got complete relief from all the associated symptoms. The Ayurvedic medicines are still continued. This case report demonstrates the successful integrative management of a chronic case of Diabetes mellitus, in a male patient, whose blood sugar control was very poor, in spite of taking conventional medicine.
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A 37-year-old male patient is a known case of Type 2 Diabetes mellitus since 3 years. He presented with excessive tiredness, weight loss, polyuria and polydipsia, and pain in the soles of the feet for 8 months. He also experienced stress, anxiety, overthinking and memory loss. He had consulted an allopathic doctor at the onset of symptoms in 2019. The biomedical diagnosis was DM type 2 based on the HbA1c value. He tried Insulin for 3 months. Stopped Insulin and then started taking anti-diabetic medications. But in spite of taking medicines, the blood sugar control was very poor and the symptoms persisted. So he consulted Dr Partap Chauhan for better management of the condition. The ayurvedic diagnosis was Prameha. The line of treatment followed was vata-pitta and vata-kapha shamana, medhya, rasayana and sroto shodhana. With 5 months of ayurvedic treatment along with diet and lifestyle modification, he was able to reduce the dosage of his concomitant medicine. The HbA1c reduced to 7.4 from 10.9 recorded at baseline, indicating good blood sugar control. He got complete relief from all the associated symptoms. The Ayurvedic medicines are still continued. This case report demonstrates the successful integrative management of a chronic case of Diabetes mellitus, in a male patient, whose blood sugar control was very poor, in spite of taking conventional medicine.
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Timeline
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Tabulated Summary
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Narrative
TITLE OF CASE
Integrative management of Integrative management of Type 2 Diabetes mellitus - A case report
Dr Partap Chauhan
ABSTRACT
A 37-year-old male patient is a K/C/O Type 2 DM. He presented with excessive tiredness, weight loss, polyuria and polydipsia, and pain in the soles of the feet for 8 months. He also experienced stress, anxiety, overthinking and memory loss. He had consulted an allopathic doctor at the onset of symptoms in 2019. The biomedical diagnosis was DM type 2 based on the HbA1c value. He tried Insulin for 3 months. Stopped Insulin and then started taking anti-diabetic medications. But in spite of taking medicines, the blood sugar control was very poor and the symptoms persisted. So he consulted Dr Partap Chauhan for better management of the condition. The ayurvedic diagnosis was Prameha. The line of treatment followed was vata-pitta and vata-kapha shamana, medhya, rasayana and sroto shodhana. With 5 months of ayurvedic treatment along with diet and lifestyle modification, he was able to reduce the dosage of his concomitant medicine. The HbA1c reduced to 7.4 indicating good blood sugar control. He got complete relief from all the associated symptoms. The Ayurvedic medicines are still continued.
KEYWORDS
Integrative, ayurveda, prameha, diabetes, case report, type 2 diabetes mellitus
INTRODUCTION
Diabetes is a chronic metabolic disorder, characterised by constant elevated blood sugar levels. This can be caused by various reasons, the improper breaking down of the body sugar and its absorption. The excess sugar is released into the blood stream, thus causing an elevated blood sugar level. There are 3 types of Diabetes:
Type 1- This is considered as an auto immune reaction, where the body stops producing insulin. 5-10 % diabetics are of Type 1. The symptoms develop very quickly, and children, teens and adults are diagnosed with this Type. There is no prevention yet identified for Type 1.
Type 2- This is normally referred to as Adult onset Diabetes. Lack of Physical activity, obesity and unhealthy lifestyle are the risk factors for this Type of Diabetes. In the Pre-diabetes state, by adopting lifestyle changes and diet, this can be reversed. 90-95 % of the diabetics are of Type 2.
Type 3- Gestational Diabetes is normally referred to as Type 3. This prevails during pregnancy and after delivery, this is resolved in majority of the patients. But once the patient gets gestational diabetes, there is a possibility of becoming diabetic in the due course of time. Regular check up of blood sugar is advised.
Diagnostic criteria- Hb A1C is considered as the main diagnostic parameter, for Diabetes Mellitus. If the HbA1C is less than 5.7, it is normal. When the values are 5.7 to 6.4, it is considered to be Pre-diabetes. When the value is 6.5 and higher, then it is Diabetes. When the value is above 8, then it is considered to be poor control of Diabetes.
PATIENT INFORMATION
The patient is a 37 year old male, presenting with excessive tiredness, weight loss, polyuria and polydipsia, and pain in the feet soles for 8 months. He also experiences stress, anxiety, overthinking and memory loss. The patient was a known case of Type 2 Diabetes Mellitus for 3 years. Even with different anti-diabetic medications, HbA1c was in poor control. His Ayurvedic consultation was in September 2022.
Family History- Both his parents were diabetic.
Psychosocial History- He was very stressed and anxious.
CLINICAL FINDINGS
General examination was done.
TIMELINE
Image 1. Timeline of events added below
DIAGNOSTIC ASSESSMENT
Modern Diagnostic parameter; The blood reports prior to starting the Ayurvedic treatments were noted as the Baseline. The patient had a confirmed Biomedical diagnosis as DM type 2, based on his HbA1c value.
Image 2. Blood reports dated June and September 2022 added below
Ayurvedic Assessment was done based on the presenting complaints, the confirmed diagnosis from the allopathic physician
Differential Diagnosis- Does not apply as the patient came in with a definite diagnosis.
Prognosis & Treatment available: In Type 2, making drastic changes in the diet and lifestyle can produce a major change in the Blood sugar levels. Exercise and less-carb diet is the key to maintaining the blood sugar levels under control. This helps in the Pre-diabetes phase. When the patient reaches the Diabetic phase, then medical intervention supported by diet and lifestyle is the treatment protocol. If the blood sugar remains elevated inspite of taking medicines, then it can cause complications like damage to the microvascular vessels. If the sugar level is alarmingly high then insulin injection may be advised. In this patient, in August 2022, inspite of taking anti-diabetic medicine, his HbA1c was recorded as 10.5 indicating a poor sugar control.
THERAPEUTIC INTERVENTION
Please refer the tab ‘Treatment’ in the Portal.
FOLLOW-UP AND OUTCOMES
Both objective and subjective parameters were assessed to analyse the outcome of the ayurvedic treatment.
Subjective parameters: After 2 weeks of starting ayurvedic treatments, he got moderate relief from his symptoms. After 3 months of treatment, significant improvement in sleep. He got relief from all associated symptoms. His anti-diabetic medication dose could be tapered.
Objective parameters: The HbA1c value was also showing a decrease in levels. The last follow up was in Feb 2023, where the HbA1c was recorded as 7.4 indicating a good control. He was free from all his symptoms.
Clinician-based assessment; With the 5 months of ayurvedic treatment along with diet and lifestyle modification, he was able to reduce the dosage of concomitant medicine. Blood sugar level is now under control with no associated symptoms. Ayurvedic medicines are still continuing.
Patient-assessed; Not relevant
Midpoint evaluation:
Image 3. CGM Report dated September 21st to 5th October
Endpoint Evaluation:
Image 4. Blood report dated Feb 2023
Intervention adherence and tolerability – The patient adhered to the prescribed treatments and tolerated the treatments well.
Method of assessment- By monitoring the patient.
Adverse and unanticipated events; None reported
DISCUSSION ;
The patient had a chronic history of Diabetes mellitus since 2019. Inspite of taking anti-diabetic medicines, his HbA1c was still showing a poor sugar control. He started Ayurvedic treatments in 2022. The treating physician targeted at pacifying the aggravated dosas- Vata-Kapha and Vata-Pitta. Apart from this, srotoshodhana was also planned, followed by Rasayana. The last follow up by the patient recored the HbA1c value as 7.4 indicating a good control. Regular follow ups are advised.
PATIENT’S PERSPECTIVE
Not available.
LEARNING POINTS/TAKE HOME MESSAGES
Even in patients of chronic DM with poor response to anti- diabetic medicine, an integrative management could help bring the blood sugar under control. Further the regular dose of the anti-diabetic medicine could be tapered.
INFORMED CONSENT
Written consent obtained from patient for publishing of the case report in the Portal
ACKNOWLEDGEMENTS
None specified
CONFLICT OF INTEREST
None declared.
FUNDING
None
REFERENCE
- American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care. 2013;36 Suppl 1(Suppl 1):S67-S74. doi:10.2337/dc13-S067
- Murthy AR, Singh RH. Concept of prameha/madhumeha (contradictions and compromises). Anc Sci Life. 1989;9(2):71-79.
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Immersive Learning
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Modern Diagnosis
BIOMEDICAL DIAGNOSIS: Diabetes mellitus Type 2
ABOUT THE DISEASE:
Diabetes is a chronic metabolic disorder, characterised by constant elevated blood sugar levels. This can be caused by various reasons, the improper breaking down of the body sugar and its absorption. The excess sugar is released into the blood stream, thus causing an elevated blood sugar level. There are 3 types of Diabetes:
Type 1- This is considered as an auto immune reaction, where the body stops producing insulin. 5-10 % diabetics are of Type 1. The symptoms develop very quickly, and children, teens and adults are diagnosed with this Type. There is no prevention yet identified for Type 1.
Type 2- This is normally referred to as Adult onset Diabetes. Lack of Physical activity, obesity and unhealthy lifestyle are the risk factors for this Type of Diabetes. In the Pre-diabetes state, by adopting lifestyle changes and diet, this can be reversed. 90-95 % of the diabetics are of Type 2.
Type 3- Gestational Diabetes is normally referred to as Type 3. This prevails during pregnancy and after delivery, this is resolved in majority of the patients. But once the patient gets gestational diabetes, there is a possibility of becoming diabetic in the due course of time. Regular check up of blood sugar is advised.
Diagnostic criteria- Hb A1C is considered as the main diagnostic parameter, for Diabetes Mellitus. If the HbA1C is less than 5.7, it is normal. When the values are 5.7 to 6.4, it is considered to be Pre-diabetes. When the value is 6.5 and higher, then it is Diabetes. In this patient, the diagnosis was confirmed with HbA1C recorded as 11.5 at Baseline (2019).
When the value is above 8, then it is considered to be poor control of Diabetes. The 37 year old male patient was put on Insulin injection for 3 months, to bring the blood sugar under immediate control, and then started with anti-diabetic medicine. He did not take the medicine for 6 months, without any medical advise and the blood sugar levels started fluctuating again.
Image 1. Prior Reports of HbA1c dated June and September 2022.
Prognosis & Treatment available: In Type 2, making drastic changes in the diet and lifestyle can produce a major change in the Blood sugar levels. Exercise and less-carb diet is the key to maintaining the blood sugar levels under control. This helps in the Pre-diabetes phase. When the patient reaches the Diabetic phase, then medical intervention supported by diet and lifestyle is the treatment protocol. If the blood sugar remains elevated inspite of taking medicines, then it can cause complications like damage to the microvascular vessels. If the sugar level is alarmingly high then insulin injection may be advised. In this patient, in August 2022, inspite of taking anti-diabetic medicine, his HbA1c was recorded as 10.5 indicating a poor sugar control.
Reference
American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care. 2013;36 Suppl 1(Suppl 1):S67-S74. doi:10.2337/dc13-S067
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Ayurveda Diagnosis
AYURVEDIC DIAGNOSIS: Prameha
ABOUT THE DISEASE:
The Biomedical diagnosis in this case report is Diabetes Mellitus Type 2. The Ayurvedic physician has diagnosed this condition as Prameha. The specific type was not mentioned by the treating physician. But taking into account the chronicity of the condition and that it was not responding even to the anti-diabetic medicine, this can be attributed to being Madhumeha.
The word Prameha is derived from Pra – means excess, Meha – ksharane - passing of urine. ‘Pra’ means excess and ‘Meha’ means ‘ksharaNe’ (ie) passing of urine. Prameha can be defined as the disease characterised by passing excess urine. The Classical Texts also mention the turbid appearance of the urine.
प्रभूताविल मूत्रता......
Apart from this, symptoms like Malina danta, hasta pada daha, deha chikkanata, trshna, madhurya asya, madhu samana varna, angagandha, shithilangata are also mentioned.
Causative Factors: Lack of physical activity and inappropriate diet are the main causes. Kapha and medas are aggravated and dhatu shaithilya manifests. Prameha can be Sahaja (hereditary) or Apathya nimittaja (Unsuitable food and activities). Depending on the predominance of the Dosa, there are 20 types of Prameha listed in the textbooks. They are 10 Kaphaja, 6 Pittaja and 4 Vataja types.
Prognosis of Prameha: According to Caraka, in patients with early onset, is sthula and the origin of the disease is Apathyaja, it is sadhya. Pittaja and certain types of Kaphaja Prameha are yapya. This can be managed with palliative care. Vataja and Sahaja type of prameha, in a krsha, the prameha is said to be asadhya. The 37 year old male patient has started allopathic treatment 3 years back, with 3 months of Insulin injection, followed by anti-diabetic medicine. Inspite of this, his HbA1c was recorded very high indicating a poor sugar control.
Treatment & rationale for treatment: The patient is identified as Sthula pramehi or Krsha Pramehi. In sthula pramehi, अपतर्पणयुक्तिभिः is the treatment adopted. In a Krsha pramehi, अन्नपानप्रतिसंस्कृताभिः is the line of treatment followed.
Rationale of treatment explained by the Physician: Here, the treatment was internal medications. The logic of using medicines and their targets as explained is tabulated below.
NAME OF THE MEDICINE
RATIONALE FOR USING THIS MEDICINE
Madhumehantak churna
Vata kapha shamana, sroto shodhana
Vijaysar churna
Srotoshodhana, Rasayana
Tejovatyadi churna
Vata kapha shamana, Srotoshodhana
Aampachak churna
Deepana, Pacana, Vatanulomana, Srotoshodhana
Udumber ghan sattva
Pitta vata shamana, Rasayana
Chandraprakash rasayan vati
Vata pitta shamana, Srotoshodhana, Rasayana
Tab Diabetes
Vata kapha shamana, Srotoshodhana, Pacana
Tab. Diaboherb
Vata kapha shamana, Srotoshodhana, Rasayana
Tab. Strees free
Medhya Rasayana
Cap. Kutaki
Vata pitta shamana, Rasayana, Recana, Srotoshodhana
In continuation with this, follow up medicines like Yakrada vati, Tab. Diatreen, Tab. Arogyadayini,Tab. Tryoushanadi,Gokshuradi guggulu,Udaramrit vati / Shankh vati were also prescribed.
Reference
Murthy AR, Singh RH. Concept of prameha/madhumeha (contradictions and compromises). Anc Sci Life. 1989;9(2):71-79.
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Treatment
Name of Medicine Dosage Form Dosage Mode of Administrtation From - To (Date) Medicine Reference Madhumehantak Curna Curna 0.75gm Oral, with warm water 2022-09-12 - 2023-09-16 Patent and Proprietary Medicine Vijaysar Curna Curna 0.75gm Oral, with warm water 2022-09-12 - 2023-09-16 Patent and Proprietary Medicine Tejovatyadi Curna Curna 0.75gm Oral, with warm water 2022-09-12 - 2023-09-16 Patent and Proprietary Medicine Amapacaka Curna Curna 0.75gm Oral, with warm water 2022-09-12 - 2023-09-16 Patent and Proprietary Medicine Udumber ghan sattva Capsule 1 Twice daily with warm water 2022-09-12 - 2023-09-16 Patent and Proprietary Medicine Chandraprakash rasayan vati Tablet 2 Twice daily with warm water 2022-09-12 - 2023-09-16 Patent and Proprietary Medicine Tablet Diabetes Capsule 1 Twice daily with warm water 2022-09-12 - 2023-09-16 Patent and Proprietary Medicine Tab. Diaboherb Capsule 1 Twice daily with warm water 2022-09-12 - 2023-09-16 Patent and Proprietary Medicine Tab. Strees free Capsule 1 At bedtime with warm water 2022-09-12 - 2023-09-16 Patent and Proprietary Medicine Cap. Kutaki Capsule 1 Once daily with warm water, in the afternoon 2022-09-12 - 2023-09-16 Patent and Proprietary Medicine -
Outcome Measures
OUTCOME MEASURES
The 37 year old male patient was diagnosed with Type 2 Diabetes mellitus in 2019. He tried 3 months of Insulin injection followed by internal anti-diabetic medicine. But even after 3 years, the HbA1c still recorded high value indicating a poor blood sugar control. Also he had associated symptoms like stress, anxiety, overthinking and memory loss. He also excessive tiredness, weight loss, polyuria and polydipsia, pain in the feet soles.
Assessment: Both objective and subjective parameters were assessed to analyse the outcome of the ayurvedic treatment.
Subjective parameters: After 2 weeks of starting ayurvedic treatments, he got moderate relief from his symptoms. After 3 months of treatment, significant improvement in sleep. He got relief from all associated symptoms. His anti-diabetic medication dose could be tapered.
Objective parameters: The HbA1c value was also showing a decrease in levels. The last follow up was in Feb 2023, where the HbA1c was recorded as 7.4 indicating a good control. He was free from all his symptoms.
Table 1. The Subjective and Objective parameters tabulated date-wise.
Symptoms
Sep 22
Oct 22
Dec 22
Feb 23
Tiredness
++++
++
Absent
Absent
Constipation
++++
++
+
Absent
Frq. Urination
+++
++
+
Absent
Stress/Anxiety
++++
+++
++
+
FBS
233.85
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110-130
134
PPBS
-
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130-150
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HBA1C
10.9%
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8.2%
7.4%
During the Ayurvedic treatment, the blood sugar value reports indicated that the response to the treatment was good.
Image 1. CGM Report recorded from 21st September to October 5th
Image 2. Blood report dated December 2022
Image 3. Endpoint Blood sugar level recorded on Feb 2023
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