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Standalone Ayurvedic management of a chronic case of Juvenile Idiopathic Arthritis in a young male with poor response to NSAIDs and DMARDs-A Case report

Dr G Syamakrishnan

ABSTRACT

A 21-year-old male patient was diagnosed with Juvenile Idiopathic Arthritis1 at the age of 12. He suffered from joint pain- both major and minor on and off. He would take conventional medicines and get relief. But since the past 4 months, despite taking conventional medicine, he was not getting relief from the joint pain. His CRP value was constantly elevated. His Rheumatologist suggested taking Disease Modifying Anti Rheumatic Drugs like Adalimumab / Etanercept, to control the symptoms, but patient was not willing. So, he approached Dr Syamakrishnan, presenting with major and minor joint pain and difficulty in movement. The pain was severe in the knees and neck. This was diagnosed as Pitta Kapha Pradhana Vatashonita2 in the amavastha. After 5 months of Ayurvedic medicines, he got complete relief from his symptoms and his elevated CRP value became normal. For the past 1 year, the patient has had no complaints and is in remission.

KEYWORDS

Juvenile Idiopathic Arthritis, Vatashonita, Vatarakta, Ayurveda

INTRODUCTION

Juvenile idiopathic arthritis indicates a spectrum of arthritic symptoms whose cause is unknown, and symptoms manifest before 16 years of age. This term includes several categories of diseases, each of which presents distinctly, with its characteristic clinical manifestations, and mostly has a genetic background and etiopathogenesis. There is no definitive cure from the available treatment options, but the disease can be managed with medicines.

Diagnostic Criteria- There are no specific diagnostic criteria for this condition. The ESR and CRP are taken as associated factors indicating the extent of inflammation in the body. The diagnosis is made basically by clinical evaluation, supported by blood parameters.

Prognosis- The condition may resolve within months, but some, suffer from the complaints lifelong. Juvenile idiopathic arthritis can cause serious complications, such as growth problems, joint damage and eye inflammation. So appropriate medical intervention is mandatory.

PATIENT INFORMATION

A 21-year-old male patient, a physiotherapy student suffered from major and minor joint pain and restricted movements. Associated complaints were severe pain mainly in the knee and neck. He was under treatment by a Rheumatologist for 4 months but was not responding. No significant family, genetic and psychosocial history. Surgical History: Knee joint aspiration at the age of 9, following trauma. The patient has no addictions.

Medical History: Patient was diagnosed with Juvenile Idiopathic Arthritis at the age of 12.  At the age of 12, he had trauma in the knee and developed swelling in both knee joints. He underwent aspiration of fluid from knee joint twice and took conventional medication for it. Developed arthritis following this and was cured after 10 months of conventional medication. RF and, HLA B 27 were Negative. In 2015 he had recurrent episodes of myalgia and was managed by fomentation and pain balms (self-prescribed). In 2018 March developed generalised arthritis- general joint pain. He consulted a Rheumatologist and started allopathic medicines. But he did not get significant relief and his CRP value was high. So, he decided to stop conventional medicines and opt for Ayurveda.

CLINICAL FINDINGS

Swelling in B/L knee joints, Pain, Knee, Neck, Shoulder, Elbow, Wrist, and Interphalangeal joints. Fever.

Physical examination: Antalgic gait, Erythematous lesions in body. Joint tenderness, Restricted Joint movements.

TIMELINE

Image 1. Timeline of events attached below

DIAGNOSTIC ASSESSMENT

Modern Diagnostic parameter: There are no specific diagnostic criteria for this condition. The ESR and CRP are taken as associated factors indicating the extent of inflammation in the body. The diagnosis is made basically by clinical evaluation, supported by blood parameters.  In this case report, the patient was already diagnosed at the age of 12 years by a Rheumatologist and has had joint complaints on & off for many years.

Confirmed Diagnosis Documents & previous medicines:

Image 2. Confirmed diagnosis documents and previous medicines  

Image 3. Blood reports at baseline attached below

Ayurvedic Assessment was done based on the clinical evaluation by the ayurvedic physician, the confirmed diagnosis from the modern hospital.

Differential Diagnosis- This does not apply as the patient came in with a definite diagnosis.

Prognosis- The condition may resolve within months, but some, suffer from the complaints for a longer duration. Juvenile idiopathic arthritis can cause serious complications, such as growth problems, damage to the joints and eye inflammation. So appropriate medical intervention is mandatory. This patient was non-responsive to the standard of care that he was given.

THERAPEUTIC INTERVENTION

See the tab 'Treatment Details'

FOLLOW-UP AND OUTCOMES

Both subjective and objective parameters were assessed. At the end of the ayurvedic treatment, the patient got complete relief from symptoms. The CRP level became normal and remained stable even after stopping the ayurvedic treatments.

Patient-assessed: Not relevant

Follow up test results: Blood parameters- CRP was continuously monitored throughout and after treatment also.  

Image 4. Blood reports at midpoint and endpoint attached below

Table 1. CRP Values before and after Ayurvedic Treatment

	Date	CRP Values       (Normal value  <6 mg/L)
Before Treatment	8- 7- 17	84
	3 - 3 -18	34.9
	28 - 4- 18	78.03
After Treatment	1-8-18	2.66
	12-10-18	1.3
	10-12-18	3.78

Intervention adherence and tolerability – The patient adhered to the prescribed treatments and tolerated the treatments well.

Method of assessment- By monitoring the patient and the CRP level.

Adverse and unanticipated events: Initially after 5 days of medication, he developed complaints of hemorrhoids, bleeding per rectum, cracks in lips, raw tongue, chest pain, night fever, cough, constipation, etc. which resolved completely on changing an unhealthy diet like red chillie, bread etc. There were no medicines prescribed to manage this condition. These symptoms were managed just with changes in diet.

DISCUSSION:

The basic principle of treatment in Ayurveda is to assist the body in self-healing, rather than suppressing symptoms. Importance is given to the stage of disease than the disease proper. Treatments may be categorised into 3 stages. The first stage is (ama) a Metabolic/Immune toxic stage where the body is striving hard to eliminate the toxic radicals. Here the symptoms and signs may be severe but should not suppress symptomatically. Using painkillers, external applications and food and regimes suppress the symptoms, that Ayurveda does not propagate. Because it will only mask the disease process and make it a chronic one with remissions and exacerbations. (Vishama / Leena dosha). This case is a classic example of this. The first line is to avoid food and regimes which cause tissue toxicity. Mainly to avoid heavy dinner, Junk foods, highly processed food items, Addictive like black tea etc. And to follow a healthy lifestyle. So here pacana drugs (Antioxidants like acting drugs) were prescribed aiming at disintegration and elimination of metabolic toxins. Before entering the second stage a safe and transitional stage of medication was tried, wherein a smaller dose of Sneha (medicated fats) was administered along with decoctions to check the tolerance. As it was well tolerated, this was followed by smaller doses of sneha alone. The positive results assured that the body has attained the nontoxic stage or niramavastha and is fit for Sneha.

Then the Shamana dose of Sneha was administered to strengthen the system. This gave full symptomatic relief, and the blood parameters also normalised. To prevent the recurrence Rasayana drugs were prescribed. Even after stopping the medicines, the lab parameters remained stable. He has not reported any recurrence after one year of stopping the ayurvedic medicines. This shows the positive compliance of the Ayurveda approach. Sweda is generally contraindicated in Vatashonitam, and cause complications. Avipatti curna virechana in daily dose augmented the net outcome of the treatment by blood purification which will help to prevent a recurrence.

PATIENT’S PERSPECTIVE

Not available.

LEARNING POINTS/TAKE-HOME MESSAGES

A 21-year-old male patient, with a confirmed diagnosis of Juvenile Idiopathic Arthritis has been taking conventional medicine on & off since the age of 12. During the latest episode, being non-responsive to conventional medicine for 4 months, he opted for Ayurveda. With 5 months of ayurvedic medication, he got complete relief from symptoms and his CRP became normal. Even after stopping ayurvedic medicines, the CRP remained stable.

INFORMED CONSENT

Written consent was obtained from the patient.

ACKNOWLEDGEMENTS

None

CONFLICT OF INTEREST

None declared.

FUNDING

None

REFERENCE

1. Barut K, Adrovic A, ?ahin S, Kasapçopur Ö. Juvenile Idiopathic Arthritis. Balkan Med J. 2017 Apr 5;34(2):90-101. doi: 10.4274/balkanmedj.2017.0111. PMID: 28418334; PMCID: PMC5394305.
2. Gupta, A., and S. Sharma. “Concept of Gouty Arthritis (Vatarakta) in Ayurveda”. Himalayan Journal of Health Sciences, Vol. 5, no. 3, Dec. 2020, pp. 56-61.  doi:10.22270/hjhs.v5i3.80.

 

Image 1. Timeline of events 

Image 2. Confirmed diagnosis documents and previous medicines  

Image 3. Blood reports at baseline dated March 2018 and April 2018 attached below

Image 4. Blood reports at midpoint and endpoint attached below