AYURVEDIC MANAGEMENT OF PANDU (ANAEMIA)

Anaemia refers to a state in which the number of red blood cells or level of haemoglobin in the blood is below the normal range appropriate for age and sex. Haemoglobin is needed to carry oxygen and if you have too few or abnormal red blood cells, or not enough haemoglobin, there will be a decreased capacity of the blood to carry oxygen to the body’s tissues. Others factors such as pregnancy, smoking habits and altitude also affect haemoglobin levels and must be taken into account when considering an individual is anaemic. Anaemia is a serious global public health problem that particularly affects young children and pregnant women. WHO estimates that 42% of children less than 5 years of age and 40% of pregnant women worldwide are anaemic. This results in symptoms such as fatigue, weakness, dizziness and shortness of breath, among others. The most common causes of anaemia include nutritional deficiencies, particularly iron deficiency, though deficiencies in folate, vitamins B12 and A are also important causes; haemoglobinopathies; and infectious diseases, such as malaria, tuberculosis, HIV and parasitic infections.

Anaemia refers to reduction in

• Red blood cell count
• Haemoglobin content
• Packed cell volume

 

Basically it is the condition when the haemoglobin content is decreased below normal level.

RBC count : (Aprox.)

In males : 5.5 million/Cumm.

In female : 4.5 million/Cumm.

 

Nomal Values

• Mean corpuscular volume (M.C.V.) – This is the average volume of R.B.C.

Normal value of M.C.V. = 80-100 μ3

• Mean corpuscular hemoglobin (M.C.H.) – (This is the amount of hemoglobin present in average R.B.C.)

Normal value of MCH = 25-30 Pico- gram

• Mean corpuscular hemoglobin concentration (MCHC) – This is the amount of Hb present in 100 ml of RBC is called MCHC.

Normal value of MCHC = 34.5 gm/100 ml of RBCs.

• The average life span of RBC is 120 days. Erythropoesis means production of red blood cells ie. RBCs. After birth, the main site of erythropoesis is bone marrow. During early years of life, all bones are filled up with active marrow. By the age of 20 years, only the upper end of long bone contains active red marrow. Complete erythropoesis occurs in 7 days.

FACTORS AFFECTING ERYTHROPOIESIS

• Anoxia: oxygen tension in tissues. This stimulates bone marrow for Erythropoiesis
• Diet: diet rich in essential amino acids for the synthesis of globin part of hemoglobin.
• Synthesis of DNA
• Vitamins :
• Maturation of RBC : Vit C, B6, B12, Nicotinic acid and folic acid
• Vitamin B12/Cyanocobalamine(Extrinsic factor):Its poor absorption from intestine by blood due to lack of intrinsic factor (I.F.)  which is secreted   in gastric juice
• Vitamin B6 and C – Both of these are helpful in erythropoiesis.
• Vitamin C is helpful in Iron metabolism.
• Hormones: Certain endocrinal hormones induce erythropoiesis.
• Metal : Effects erythropoiesis by affecting Hb synthesis

 

CAUSES OF ANAEMIA

Anaemia is essentially caused by two basic pathways

– By a decrease in production of red blood cell or hemoglobin

–  By a loss or destruction of blood.

Anemia results when the balance between production and destruction is disturbed as follows

• Inadequate production of RBC in marrow due to: Lack of raw materials required for erythropoiesis.e.g. Iron, B12, folic acid, proteins.
• Depression of the bone marrow. e.g. chonic infections, chronic renal failure, radiation, cytotoxic drugs ,hypothyroidism, sensitivity reaction to drugs, or viral infections, congenital.
• Infiltration of marrow by leukemia cells, fibrosis, metastasis, lymphoma,e.t.c.

 

Excessive Destruction of Red cells due to:

• Abnormality of hemoglobin molecule, e.g.various hemoglobinopathies and Thalassemias
• Deficiency of red cell enzymes: e.g. glucose-6-phosphate dehydrogenase. Pyruvate kinase. Glutathione synthesis e.t.c.
• Abnormality of red cell membrane. E.g. hereditary spherocytosis & non- sphyrocytosis hemolytic anemias e.t.c.
• Auto-immune hemolytic anemias.

 

CLASSIFICATION OF ANAEMIA

Anaemia can be classified by two methods namely:

1. Morphological classification
2. Etiological classification

 

Morphological classification: On the basis of the size and haemoglobin content of red blood cell, the anaemia is classified into six types.

• Normocytic Normochromic Anaemia

The size of red blood cell and haemoglobin content are normal. Only red blood cell count is reduced.eg. sudden loss of blood due to ante partum, post partum haemorrhage , Haemolytic anaemia, Infections, Aplastic Anaemia,  Pure red cell aplasia Hypothyroidism, Chronic hepatic and renal diseases,  Myeloproliferative disorders : Leukemia, Hemolytic anaemia : G-6-PD deficiency, hereditary spherocytosis, Sickle cell anaemia

• Macrocytic Normochromic Anaemia

The red blood cells are larger in size and due to this the red blood cell count is reduced.eg.

Deficiency of haemopoietic factors like Vit B12, folic acid, Vit. C  and thyroxine, Liver diseases.

• Macrocytic Hypochromic Anaemia

The red blood cells are immature and larger in size and the heamoglobin content in the cell (Mean Corpuscular Haemoglobin- MCH) is less. Intense activity of the bone marrow as in hemolytic anemia, thalassemia

• Microcytic Hypochromic Anaemia

The red blood cells are smaller in size and the heamoglobin content in the red blood cell (Mean Corpuscular Haemoglobin- MCH) is less. Nutritional anaemia Pyridoxine responsive anaemia Post hemorrhagic anaemia Dys-erythropoietic anaemia, Thalassemia Lead poisoning eg. Iron deficiency anaemia

• Microcytic Normochromic Anaemia : Chronic infections Malignant diseases
• Normocytic- Hypochromic Anaemia : Deficiency of iron through – defective absorption. – Excessive demand i.e. infancy, puberty and pregnancy.

 

Etiological classification: On the basis of the etiology (cause of the disease) such as impaired production of RBC, deficiency of substance essential for erythropoiesis like Iron, Vitamin B12 (extrinsic factor), folic acid, Vitamin C, Vitamin B6 etc., the anaemia is divided into four types

• Haemorrhagic anaemia : excessive blood loss; :

1. a) Acute: – Trauma Scurvy Hemophilia
2. b) Chronic:- Lesion of G.T. Tract – Bleeding peptic ulcer, bleeding piles Gynecological disturbances.

• Haemolytic anaemia : Hemolysis means excessive destruction of red blood cellswhich occurs due to
• Intrinsic (Intracorpuscular) abnormalities of Red cells –

Abnormal shape: – Spherocytosis Elliptocytosis

Abnormal Hb : – Sickle cell anaemia

• Extrinsic (Extra corpuscular) abnormalities

Antibody mediated : -Transfusion reactions Erythroblastosis faetalis

Drug associated S.L.E. Mycoplasma infection

• Mechanical trauma to red cells:- Thrombocytopenic purpura DIC Infection : , Malaria Chemical injury : -Lead poisoning

Animal poison : – Snake venom

• Nutrition deficiency anaemia

Nutritive substances such as iron, proteins, and vitamins like vitamin B12, vitamin C and folic acid are necessary for erythropoiesis. The deficiency of these substances leads to nutrition deficiency anaemia. The anaemias of this category are

• Iron deficiency anemia– Iron deficiency anemia develops due to inadequate availability of iron for haemoglobin synthesis. The red blood cells are microcytic and hypochromic. Iron deficiency occurs because of the following reasons
• Loss of blood
• Decreased intake of iron
• Poor absorption of iron from intestine
• Increased demand for iron in conditions like growth and pregnancy
• Special features of iron deficiency anaemia are brittle nails, spoon shaped nails, brittle hair, trophy of papilla in tongue and dysphagis
• Protein deficiency Anaemia – Due to deficiency of proteins, the synthesis of haemoglobin is reduced. Hence the cells are hypochromic
• Pernicious Anaemia or Addison’s anaemia – Is due to the atrophy of gastric mucosa resulting in reduced production of intrinsic factor and poor absorption of Vitamin B12. Atrophy of gastric mucosa may occur due to autoimmune destruction of parietal cells. The synthesis of haemoglobin maybe almost normal and the cells are macrocytic and normochromic. This anaemia is common in old age and is more in females than in males. This is associated with other auto immune diseases like disorders of thyroid gland, Addison’s disease etc. The characteristic features include lemon yellow colour of skin (due to anaemic pallour and mild jaundice), red sore tongue. Neurological disorders such as paresthesia ,progressive severe weakness and ataxia are also observed in extreme conditions
• Megaloblastic Anaemia – This is due to deficiency of another maturation factor called folic acid. Folic acid deficiency occurs because of poor intake or poor absorption. The maturation of cells does not occur. The red blood cells are large with immature nuclei. The nucleus remains immature because of defective DNA synthesis. The reason for defective DNA is the lack of folic acid or abnormal folic acid metabolism. The cells are macrocytic and hypochromic. The features are similar to pernicious anaemia without the neurological symptoms.

• Aplastic anaemia – It is due to the disorder of red bone marrow. The red bone marrow is reduced and replaced by fatty tissues in conditions like repeated exposure to x-rays or gamma radiation and by bacterial toxins, quinine, gold, salts, benzene, radium etc. It is common in Tuberculosis and viral infections like Hepatitis and HIV infections.

 

AYURVEDIC CONCEPT OF ANAEMIA: PANDU

      Pandu roga is generally considered as anaemia in Ayurveda. Pandu means pallor. In this disease there is pallor on the skin, due to due to deficiency of blood tissue either in the form of haemoglobin or red blood cells (RBC), hence it is called anaemia.

NIDANA / CAUSES

Aharaja (Foods)

• Kshara (alkaline)
• Amla(sour)
• Lavana (salt )
• Ati ushna (hot and spicy)
• Viruddha (mutually incompatible foods)
• Asatmya (unwholesome)
• Nishpava (flat beans)
• Masha (urad dal)
• Pinyaka (oil cake)
• Tilataila (sesame oil)
• Vidagdha anna (putrid food)

 

Viharaja (Lifestyle and Activities)

• Divaswapna (indulging in day sleep)
• Vyayama (performing exercise before digestion of the food exercise)
• Maithuna (performing sex before digestion of the food )
• Prati karma (Improper administration of Panchakarma measures)
• Rutu vaishamya (disobedience of the seasonal regimens)
• Vegadharana (Suppression of the natural urges)

 

Psychological factors

• Kama (passion)
• Chinta (worry)
• Bhaya (fear)
• Krodha (anger)
• Shoka (grief)

 

SAMANYA SAMPRAPTI/ GENERAL PATHOGENESIS

Due to the indulgence of above said causative factors, there is vitiation of pitta dosha in the hridaya (heart). The vata dosha which is vitiated will dislodge this pitta and circulates to the entire body through Dasa dhamanis (ten major channels of circulation). Thus the vitiated pitta gets lodged between Twak (skin) and Mamsa (flesh/ muscle) vitiating kapha, vata, rakta, tvacha and mamsa in the process resulting in the development of various discolorations in the body like pandu (pale), haridra (yellow) and harita (green).

 

VISHESHA SAMPRAPTI / SPECIFIC PATHOGENESIS

The aggravated pitta (sadhaka and ranjaka varieties) along with vata by virtue of its usna(hot) and sukshma (penetrative) qualities destroys rakta (blood), the muscle tissue and ojus and produce pandutva (pallour) in the body

SAMPRAPTI ASPECTS

Dosha : pitta dominant – vata-kapha

Dushya : rakta, twak, mamsa and medas

Adhistana : twak- sarva sharira

Srotas : rasavaha, raktavaha

PURVARUPA/ PREMONITARY SYMPTOMS

• Tvaksphota /Cracking of skin
• Shtivana / Expectoration
• Gatrasadana /Debility
• Mrut bhakshana /Desire for eating mud
• Kuta shotha / Edema of eye sockets
• Vinmutra pitatva /Yellow discolouration of skin and faeces
• Avipaka / Indigestion
• Hrud spandana /Palpitation
• Roukshya /Dryness
• Svedabhava/ Absence of perspiration
• Shrama / Exertion

 

GENERAL SYMPTOMS

• Raktalpata / Decrease of blood
• Alpamedaska / decrease of fat
• Nisara / lifeless
• Shithilendriya / impairment or dull senses
• Vaivarnyata / discoluration
• Karnakshweda/ tinnitus
• Hata anala/ impaired digestive fire
• Annadwesha/ aversion to food
• Shrama/ exertion
• Bhrama/ fainting
• Gatra shoola/ body pain
• Jwara/ fever
• Swasa/ dyspnoea
• Gourava/ heaviness of body parts
• Aruchi/ anorexia
• Gatra mardana/ excruciating pain of body
• Gatra peeda/ body pain
• Akshi koota shoonatha/ inflammation of eyelids
• Haritha varna/ greenish discoluration
• Koota sadana/ tiredness of eyelids
• Sheerna loma/ falling of hair

 

TYPES

Vataja pandu

• Skin, urine and eyes: ruksha, krishna, aruna varna
• Toda, kampa, anaha, bhrama
• Indicate mild anaemia

Pittaja pandu

• Yellow color of feces, urine and eyes
• Yellow color of body
• Burning sensation, thirst and fever
• Diarrhea
• Signs of acidity

Kaphaja pandu

• Oral secretion, lethargy, fatigue and heaviness of body parts
• Oedema
• White color of skin, feces, urine, eyes and face(represents severe anaemia)

Sannipathaja pandu

• Fever
• Anorexia
• Nausea
• Vomiting
• Thirst
• Fatigue, tiredness and impaired senses
• Severe and febrile anaemia

Mrudbhkshanajanya pandu

• Oedema of body
• Oedema of eyelids
• Worm infestation
• Diarrhea

 

COMPLIACATIONS

• Aruchi/ Anorexia
• Pipasa/ Thirst
• Chardi/ Vomiting
• Jwara/ Fever
• Moordha ruja/ Headache
• Agnisada/ Indigestion
• Kanta shodha/ Inflammation of throat
• Dourbalya/ Weakness
• Moorcha/ Fainting
• Klama/ Tiredness
• Hrit peeda/ Chest pain
• Swasa/ Shortness of breath
• Atisara/ Diarrhea
• Kasa/ Cough
• Shoola/ Colic
• Daha/ Burning sensation
• Ajeerna/ Indigestion
• Swarabheda/ Hoarseness of voice
• Shodha/ Edema

 

TREATMENT

• Nidana parivarjana : Avoiding the causative factors
• Snehana: Oleation therapy

It is the purva karma (prior procedure) to shodhana (purification) treatment. Pandu patients have dhatukshaya (depletion of body tissues) which is due to vata dosha predominance, so there is dryness in the body. Sneha karma or oleation therapy can be performed even without any shodhana procedure. Tikta (bitter) ghee preparations are indicated as pandu is a pitta dosha predominant disease. Some of the medicated ghees for oleation are:

• Panchagavya ghrita
• Mahatikthaka ghrita
• Kalyanaka ghrita
• Dadimadi ghrita
• Katukarohinyadi ghrita
• Pathya ghrita
• Danti ghrita
• Draksha ghrita
• Haridradi ghrita
• Shodhana

 

In all types of pandu, Haritaki is advocated for virechana (medicated purgation). Other medicines that are mentioned include:

• Goomutrayukta dugdham
• Dantiphala rsa
• Draksha choorna
• Goomutra haritaki choorna for Kaphaja pandu
• Trivrut choorna in Pittaja pandu
• Aragwadha majja with Trikatu choorna
• Phala ghrita
• Tilwaka ghrita
• Dadimadya ghrita
• Pathya ghrita
• Danti ghrita
• Draksha ghrita
• Haridradi ghrita
• Doorvyadi ghrita
• Dosage
• Choorna : 5 to 10 grams with hot water
• Ghrita : 5 to 10 grams with hot water twice a day
• According to Charaka Chikitsa
• Vataja pandu : treatment must be mainly by unctuous drugs
• Pittaja pandu : treatment must be mainly by bitter drugs
• Kaphaja pandu: pungent and hot drugs
• Mrutbhakshanajanya pandu : the clay which may be composed of various undigestable and unassimilable substances obstructs the various channels. Thus it is necessary to remove by strong purgations. The following ghritas (medicated ghee) are indicated:
• Vyoshadi ghrita
• Nagakesaradi ghrita
• Shamana/ Pacifying therapy

In shamana chikitsa the following drugs are indicated

Single Drugs

• Pathya
• Amalaki
• Yashtimadhu
• Draksha
• Panchamoola
• Guda
• Tila
• Triphala
• Haridra
• Shunti
• Pippali
• Loha bhasma
• Mandooram
• Kaseesa bhasma
• Abhraka bhasma
• Vaikranta bhasma
• Swarna makshika bhasma
• Shilajit
• A combination of  a herbal churna (powder) and a single bhasma ia a good prescription with suitable anupana (adjuvant)

Compound Formulations

• Navayasa loha
• Vyoshadi choorna
• Kantavallabha rasa
• Hamsa mandooram
• Trilokyanatha rasa
• Chandrasuryatmaka rasa
• Pranavallabha rasa
• Panchanana vati
• Anandodaya rasa
• Trilokyasundara rasa
• Trimoorthi siddha rasa
• Udayabhaskara rasa
• Vangeshwara rasa
• Narayana mandooram
• Siddha mandooram

 

Avaleha used in Pandu

• Darvyadi Leha
• Dhatrayvaleha
• Drakshadi Avleha
• Manduradya Avaleha
• Triphaladya Avaleha

 

Asava-Arista

• Goudakarista
• Bijakarista
• Dhatryrishta
• Abhyarishta
• Madhavsava
• Sharkarasava
• Lohasava

 

Formulations containing Loha (Iron)

• Loha Bhasma
• Shuddha Mandoor Churna
• Tikshna Loha
• Shuddha Kasis Bhasma
• Suwarna Makshika
• Shuddha Shilajit
• Shuddha Gairik
• Navayas Churna
• Tapyadi Loha
• Punarnava Mandura

 

PATHYA- Dos

• Godhuma/ Old Wheat
• Shali/ Rice
• Yava/ Barley
• Shashtika/ Rice
• Jowar
• Mudga/ Green gram
• Pea
• Adhaki/ Pigeon pea
• Ghrita / Ghee
• Payasa/ sweet pudding
• Takra/ Buttermilk
• Jangalamamsa/ Lean meat
• Parpataka/ Fumaria indica
• Shaka (Vegetables): Bottle gourd, Bitter gourd, Snake gourd, Ivy gourd, Green leafy vegetable, Spinach, Dill, Turmeric
• Non vegetable : Shigada fish, Goat meat, Jangalamamsa/ Lean meat
• Fruits : Indian gooseberry, Grapes, Fig, Sapodilla, Banana, Mango, Dates, Pomegranate, Papaya
• Roots : Lotus rhizome, Garlic, Ginger
• Milk and Milk Products : Cow milk, Ghee, Butter, Buttermilk
• Liquids: Go-mutra(cow’s urine), Laja-Manda (scum of parched paddy), Koshna Jal (warm water), Laghu Panchamula Siddha-jala.
• Madya varga: Sauvira and Tushodaka (fermenting the boiled broken yava with husk)
• Vitamin B12 is found in:-Eggs, Fortified foods such as soymilk, Meat, Milk and milk products, Organ meats (liver and kidney), Poultry, Shell fish. The body absorbs animal sources of vitamin B12 much better than plant sources. Non-animal sources of vitamin B12 vary in their amount of B12
• Light exercise

 

APATHYA- Donts

• Guru, ruksha(heavy and dry foods)
• Katu (spicy, pungent)
• Amla (sour)
• Vidahi (foods causing burning sensation)
• Sura (fermented alcoholic drink)
• Souveeraka (by fermenting boiled barley and wheat without husk
• Beejapura/ Citrus medica or Buddha’s hand
• Tila (sesame )
• Gramya mamsa (meat of domestic animals)
• Shaka Varga – Except above mentioned vegetables
• Shimbi Varga – peas, urad dal, oil cake
• Pulses – sesame seeds, mustard
• Oils – Bijowar Taila
• Excessive drinking of water
• Divaswapa/ Daysleep
• Atapsevana/ Exposure to sun
• Ativyayama/ Excessive exercise
• Ativyavaya/ Excessive sexual activity
• Alcohol
• Anxiety
• Grief
• Anger

Editor: Dr. Anu PK

Email: editor@ayurvedam4you.webc.in