Abstract

Iron deficiency anemia (IDA) is a global public health crisis, so also in India. As per the World Health Organization's report, half of the total anemia is IDA. Ayurveda offers several formulations for the management of IDA. Given in this context, a systematic review was carried out to understand the role of Ayurvedic formulations for the management of IDA. For this purpose, articles were obtained from PubMed and through hand search process. Of the 37 articles identified, 10 articles were finally selected for the review. Of the 10 studies identified, 3 studies were (n = 10) exclusively focused on pregnant women, 2 studies (n = 10) were exclusively focused on pediatric age group, 1 study (n = 10) was exclusively focused on geriatric anemia and 4 studies (n = 10) were focused on general population. The response of most of the Ayurvedic formulations was better than Allopathic formulations and there was no untoward effect as observed with iron salts. Statistically significant results were obtained in favor of most of the Ayurvedic formulations in subjective and hematological parameters. Among six different formulations, Sarva-Jvara-Hara Lauha is suggested as the drug of choice for IDA as the Hb regeneration with this drug is highest- 0.16 g/dl/day, as reported by one of the studies. In addition, Punarnavadi Mandura is currently used as an anemia correcting agent at the community level promoted by the National Rural Health Mission and is included in the Accredited Social Health Activist's drugs kit. As most of these Ayurvedic formulations are found effective against IDA, their usage should be fostered at all level in addition to modern allopathic medicines.

1. Introduction

Iron deficiency anemia (IDA) is a global public health crisis, so also in India. As per the World Health Organization's (WHO's) report, there are about two billion anemia cases globally, of which half of them are IDA.^[1] It is a serious health problem as it causes general debility, lethargy, lassitude, suboptimal work performance and in certain situations mental retardation, poor intelligence and abnormal immune response.^[2] Anemia is the late indicator of iron deficiency in the human body, hence the prevalence of iron deficiency is estimated 2.5 times higher than that of anemia.^[1],[3] Furthermore, anemia and iron deficiency lead to substantial loss of physical productivity among the adults.^[3] Similarly, IDA during pregnancy is associated with maternal mortality, preterm labor, low birth weight, and infant mortality.^[3] IDA among children affects their cognitive and motor development and increases the susceptibility of infections.^[4] As per the third National Family Health Survey (NFHS), conducted in 2005–2006 in India, the prevalence of anemia among Indian population was 70% in children aged 6–9 months, 55% in females aged 15–49 years, and 24% in males aged 15–49 years.^[5] The state of IDA is being managed with the supplementation of external iron containing drugs for which several types of modern medicines are available in the market.^[6] These modern iron formulations contain one or the other types of iron salts such as, ferrous fumarate, ferrous sulfate, ferrous glycine sulfate, ferric ammonium citrate, ferric hydroxide polymaltose complex, iron choline citrate, iron dextran, ferrous calcium citrate, iron sorbitol citrate, colloidal iron hydroxide, ferrous gluconate, ferric hydroxide, and ferrous succinate.^[7] It has been further reported that the long-term treatment of IDA with these drugs is associated with constipation, heart burn, nausea, gastric discomfort and diarrhea.^[7],[8] This was further felt that despite the availability of modern allopathic anemia correcting agents as mentioned above Ayurvedic formulations are also sufficiently available in the market. The Ayurvedic anemia correcting agents are found to be practiced since centuries.^[9] With this background, an effort was made to review various types of Ayurvedic formulations that have proved efficient in the management of IDA. In Ayurveda, the disease Pandu roga can be compared with that of IDA, especially owing to the clinical manifestation of Panduta or pallor in the whole body.^[10]

The concept of iron deficiency anemia in Ayurveda

The formation and pathogenesis of a disease in Ayurveda is linked with the vitiation of Dosha (Humors). Ayurveda describes three different humors; Vata, Pitta and Kapha, which are responsible for healthy state or causation of disease. Pandu Roga is predominantly a result of vitiation of Pitta Dosha vitiation along with other Doshas, thus Pandu Roga is a Tridoshaja (of the three humors) disease. The vitiation of Pitta Doshaleads to discoloration of the skin and pallor (Pandu) owing to reduced blood (Alpa Rakta) or vitiation of blood (Vidushya Rakta).^[11]

2. Methodology

The review of literature was carried out in two phases using PUBMED and hand search. Here, the term hand search is meant for searching the articles from cross-references of the articles selected for review and is a process of purposeful selection of articles at the stage of eligibility and inclusion which did not typically undergo the process of identification and screening. Key words used for the purpose of this literature review include “Pandu Roga,” “Iron Deficiency Anemia,” and “Ayurveda”. Of 37 articles obtained from both PubMed (n = 34) and hand search (n = 3), 10 articles were finally selected for this review. This study adopted a narrative review approach instead of a quantitative approach as used in meta-analysis. Hence, no statistical a alysis was carried out in this review. [Figure 1] is a flowchart showing the selection of articles for this review.

Figure 1: The selection of articles for review 

Inclusion and exclusion criteria

Articles published in only English language were included in the review. Furthermore, original researches were only recruited for the purpose of review which precludes review articles and theoretical research. The studies which did not fall in these categories were excluded from the review.

Data extraction and analysis

In the first phase, the articles were identified based on the objectives of the study. In the second phase, the articles identified on the basis of study objectives were pooled together for the purpose of screening by reading the titles and thereafter the abstracts. Articles were excluded at this stage which were not satisfying the inclusion criteria. After this, the eligible articles were further screened by reading the full texts and, those not meeting the inclusion criteria were excluded. By the end of this process, the eligible full-text articles meeting the inclusion criteria were included in the study.

3. Results

Of the 10 studies identified, 3 studies (n = 10) were exclusively focused on pregnant women, 2 studies (n = 10) were exclusively focused on pediatric age group, 1 study (n = 10) was exclusively focused on geriatric anemia and the rest 4 studies (n = 10) were focused on general population. The frequency distribution of various drugs upon which studies have been carried out is shown in [Figure 2]. The following [Table 1]delineates the role of different Ayurvedic formulations for the management of IDA.

Figure 2: Frequency distribution upon various drugs on which studies have been carried out

Table 1: Studies showing the role of Ayurvedic formulations on iron deficiency anemia

4. Discussion

Four distinct categories have been studied in this review which includes pediatric group, geriatric group, pregnancy group and the general population group. In the following sections, these four distinct groups have been delineated in detail. In addition, [Table 2] gives an idea of the dosage, duration and Anupana (Vehicle) of important Ayurvedic formulations for IDA.

Table 2: Dosage, duration and Anupana of important Ayurvedic formulations for iron deficiency anemia

Formulations for treatment of anemia among pediatric age group

Two studies were focused on pediatric anemia.^[12],[13] In these two studies, three different drugs have been studied for their clinical efficacy against anemia among pediatric age group; Punarnavadi Mandura, Dadimadi Ghrita^[12] and Trikatrayadi Lauha.^[13] Statistically significant results were obtained in both these studies in subjective as well as the hematological parameters.^[12],[13] In addition to the significant efficacy of these drugs, the probable mode of action have also been delineated. Punarnavadi Mandura is preferably administered with buttermilk which is having acidic pH and contains lactic acid. Iron absorption is aided by decreased pH.^[14] Furthermore, it might be possible that iron combines with lactic acid to form ferrous lactate before absorption which is used by modern allopathic medicine for the management of IDA.^[6] Alternatively, it may also happen that the proteins of buttermilk or the amino acids released after digestion may combine with iron before the absorption takes place. This point of view is also supported by the WHO as it supports the use of meat and other proteins for the absorption of iron.^[15] However, Ayurveda has a different view on the role of Punarnavadi Mandura in controlling anemia which is primarily directed toward Agni (Digestive factors).^[16] However, this concept is also indirectly related to the mechanism of absorption of iron in the gastrointestinal tract by the process of Deepana and Pachana.^[16],[17] This explanation of the action of Punarnavadi Mandura is not only applicable for the management of anemia among children but also in other age groups in which the mechanism remains the same. Punarnavadi Mandura is currently used as an anemia correcting agent at the community level promoted by National Rural Health Mission and is included in the Accredited Social Health Activist's drugs kit.^[18]
Formulations for treatment of anemia among pregnancy group

Three studies focused on the management of anemia during pregnancy with Ayurvedic preparation.^{[19],[20],[21]} In these three studies, two different drugs have been studied for their clinical efficacy against anemia among pregnant women which includes Dhatrilauha Vati^{[20],[21],[22]}and Pandughni Vati.^[19] Anemia is one of the most common complications of pregnancy and contributes directly or indirectly to 20% of deaths in third world countries.^[22] In Ayurveda, anemia during pregnancy is termed as Garbhini Pandu and is primarily caused due to vitiation Rasa Dhatu(one of the seven basic body structure described in Ayurveda). According to Ayurveda, during pregnancy, Rasa Dhatu has to shoulder three times more responsibilities than in normal individuals. It becomes responsible for the nourishment of three factors; fetus, breast and the pregnant woman. Due to this stress on Rasa Dhatu during pregnancy, there are more chances that the pregnant woman gets affected with Garbhini Pandu.^[22] Dhatrilauha Vati is composed of Lauha Bhasma, which is an iron supplement and has Deepana (Stomachic) property that leads to proper metabolism and Dhatu Poshana (tissue nourishment). Amalaki (Emblica officinalis Gaertn.) and Amruta (Tinospora cordifolia Wall. ex Sringe.) help in the nourishment of basic structural body constituents and are supportive for the absorption of iron. Yastimadhu (Glycyrrhiza glabra L.) has Shonita Sthapana (prevent bleeding tendency and normalize hematopoiesis) property. The cumulative effects of all the ingredients leads to the correction of metabolism, iron absorption and improved blood formation, thereby correction of anemia.^[19]

Formulations for treatment of anemia among geriatric age group

Of the 10 studies only one study was focused on correction of anemia among geriatric age group.^[16] The drug studied for its efficacy against anemia in old age is Punarnavadi Mandura. Anemia is common in old age with the prevalence of approximately 13% among persons with 70 years or more.^[23] Most commonly anemia in old age is associated with underlying disease such as cancer, chronic kidney disease and congestive heart failure or due to malnutrition or iron deficiency.^[24],[25] Furthermore, anemia during old age is associated with increased hospitalization and mortality.^[26] In the study, majority (90%) of the old age participants were females ^[16] and were consistent with other studies that anemia among females at the age of 70 or more is common.^[27] The drug Punarnavadi Mandura acts as an anemia correcting agent in old age owing to its several components. Triphala, Trikatu, Chitraka, Vidanga and Pippalimula have appetizing, digestive, and carminative properties which improves digestive power and ultimately absorption of the drug. The components such as Trivrita, Haritaki and Danti act as laxative which help in relieving constipation mainly found in old age. Haridra, Amalaki, Pippali, Punarnava and Trivrita were mentioned as as Panduhara(antianemic) by various Acharyas, Amalaki, Danti, Pippali, Punarnava, Kushtha and Daruharidra are documented as drugs having immuno modulatory action and antioxidant properties having the potential of providing beneficial health effects in geriatric anemia.^[16]
Formulations for treatment of anemia among general population

Four studies were focused on the general population.^{[28],[29],[30],[31]} The Ayurvedic formulations studied in these four studies for their efficacy against IDA among general population include Navayasa Lauha, Punarnavadi Mandura, Dhatri Lauha, Pradarantaka Lauha, Sarva-Jvara-Hara Lauha, Brihat Yakrdari Lauha, Dadimadi Ghrita and Trikatrayadi Lauha. There are several explanations regarding the efficacy of Ayurvedic formulations in combating IDA in general population. It is observed that a substantial portion of these Ayurvedic formulations contain organic matter that includes ascorbic acid, sugars, amino acids and organic acids, which cause better absorption of non-haem iron.^[28] Furthermore, most of the Ayurvedic formulations are administered with some Anupana (vehicle) as in the case of Navayasa Lauha and Dhatri Lauha. These two formulations are administered with honey as Anupana which is a mixture of glucose and fructose and iron may combine with these sugars for absorption. This is also advocated in Allopathic medicine as iron formulations are combined with sugars such as iron polymaltose complex and ferrous gluconate.^[32]Punarnavadi Mandura and Dhatri Lauha are also administered with buttermilk and the mechanism of action and iron absorption has been explained in this draft. Brihat Yakrdari Lauha is being administered with ginger extract which also helps in iron absorption owing to its carbohydrate and protein contents.^[33]

5. Conclusion

From this review, it is clearly evident that most of the Ayurvedic formulations studied for their efficacy against IDA proved effective. All these studies showed statistically significant results in both subjective and hematological parameters. Another advantage of these Ayurvedic formulations is that they are safe and effective against IDA at all ages and groups. A comparative study between one of the best allopathic hematinics and six Ayurvedic formulations proved that some Ayurvedic formulations are even better than the former. The efficacy is evident from various hematological parameters such as plasma iron, percent saturation, plasma ferritin and Hb%. As most of these Ayurvedic formulations are found effective against IDA, their usage should be fostered at all levels in addition to modern allopathic medicines.

Financial support and sponsorship

Nil.
Conflicts of interest

There are no conflicts of interest.

References

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About Author: Medical Consultant-Urban TB, Catholic Health Association of (CHAI), Chhattisgarh, India

Article available online/offline on: AYU, Vol. 37, Issue-3, July-December 2016, Page no.163-169, for more details please visit: www.ayujournal.org

Address for correspondence: Dr. Janmejaya Samal, C/o – Mr. Bijaya Ketan Samal, Pansapalli, Bangarada, Gangapur, Ganjam - 761 123, Odisha, India.

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