review article: on pandu wsr to iron deficiency anemia

www.wjpps.com Vol 5, Issue 3, 2016.

456

Vyas et al. World Journal of Pharmacy and Pharmaceutical Sciences

REVIEW ARTICLE: ON PANDU W.S.R. TO IRON DEFICIENCY

ANEMIA (IDA).

Dr. Hetal Vyas*, Dr. Rita Khagram

** and

Dr. Alankruta Dave

***

*Reader in Kayachikitsa Dept. Shree Gulabkunverba Ayurved College.

**Lecturer in Panchkarma Dept. Shree Gulabkunverba Ayurved College.

***Associated Professor & HOD in Kayachikitsa Dept. Institute of Post Graduate Teaching

and Research in Ayurved. Gujarat Ayurved University.- 361008.

ABSTRACT

Pandu Roga can be effectively compared with Anemia on the ground

of its similar signs and symptoms. The term Anemia can be taken

under the broad umbrella of Pandu. Anemia is defined as a hemoglobin

concentration in blood below the lower limit of normal range for the

age and sex of the individual. Pandu is an increasing in alarming rate

so affecting a large number of children and women in non-

industrialized countries, as well as Iron Deficiency Anemia has

potential consequences i. e. IDA reduces the work capacity of

individual and entire population and bringing serious economic

consequences and obstacles to national development. It is the only

nutrient deficiency which is also significantly prevalent in virtually all

industrialized nations. Asia has the highest rates of Anemia in the world. About half of the

world's anemic women live in the Indian subcontinent and 88% of them develop Anemia

during pregnancy. The situation in Asia has not improved in recent years.

KEYWORDS: Pandu, Iron Deficiency Anemia, Rakta, Blood, Hemoglobin.

INTRODUCTION

In Ayurveda, Pandu is considered as a specific disease with its own Pathogenesis and

treatment.[1]

In Pandu roga change the color of the body like pallor of skin, sclera, Nail,

Tongue etc. due to Rakta alpata means Hemoglobin level decrease than the normal level. We

can correlate this disease to Anemia in modern science. Rakta has been considered as a key

WORLD JOURNAL OF PHARMACY AND PHARMACEUTICAL SCIENCES

SJIF Impact Factor 6.041

Volume 5, Issue 3, 456-480. Review Article ISSN 2278 – 4357

Article Received on

28 Dec 2015,

Revised on 17 Jan 2016,

Accepted on 07 Feb 2016

*Correspondence for

Author

Dr. Hetal Vyas

Reader in Kayachikitsa

Dept. Shree

Gulabkunverba Ayurved

College.

http://www.wjpps.com/


457


factor for the Jeevan, Prinana, Dharana and Poshana karma of the body. Rakta gets vitiated

by Doshas, mainly by Pitta dosha and create Pandu Roga.

Anemia is a blood disorder characterized by abnormally low levels of healthy RBC cells that

delivers oxygen to tissues throughout the body. The reduction of any or all of these blood

parameters reduces the essential delivery of oxygen through the bloodstream to the organs of

the body. Iron is a mineral found in the bloodstream that is essential for growth, enzyme

development and function, a healthy immune system, energy levels and muscle strength. It is

an important component of hemoglobin and myoglobin, the type of hemoglobin in muscle

tissue. PCV also decrease in Iron Deficiency Anaemia.[2]

The commonest type of Anemia that is met with in practice is Iron Deficiency Anemia.

Children, adult Male, Females suffer the most form of this malady. Nine out of ten anemia

suffers live developing countries about 2 billion people suffer from anemia and an even larger

number of people present iron deficiency. Anemia may contribute to up to 20% of maternal

deaths.[3]

Iron Deficiency Anemia is the most common and widespread nutritional disorder in

the world. In developing countries every second pregnant woman and about 40% of

preschool children are estimated to be anaemic.[4]

On average globally 50% of the anemia is

assumed to be IDA. Globally IDA ranks number 9 among 26 risk factor. IDA is considered to

be one of most prevalent form of malnutrition.[5]

Vyutpati of Pandu

According to Amarakosha[6]

According to Amarakosha, Pandu means a white colour mixed with yellowish tingue.

According to Vachaspatyam[7]

Vachaspatya refers Pandu as mixture of white and yellow colour which resembles with the

pollen grains of Ketaki Flower.

According to Gangadhara[8]

Acharya Gangadhara describes Pandu Varna as Mlana Varna.

According to Chakrapani, Dalhana and Arundatta

Acharya Chakrapani, who was the commentator of Charaka Samhita and Dalhana and

Arunadatta, who have comment on theSushrut Samhita have explain the word “Pandu” as

Shweta, Dhusara, Shwetavabhasa, Pitavabhasa.



458


In Samskrita Dictionaries

The meaning of pandu Varna has been found as Pita samvalita, Shukla and Pitabhagarth etc.

According to Shabdastom Mahanidhi

Pandu has been kept under the disease group which are classified and named according to the

changing in colour of the body.

Monier William.[9]

has taken Pallor from Pandu Varna. After considering all these

descriptions, one may find it difficult to decide about actual colour by "Pandu Varna" but if

we give a due consideration of Samprapti of Pandu given by Acharya Charaka who has

mentioned that in Pandu there is Kshaya or loss of Varna or general complexion.[9]

Acharya

Charaka has also mentioned the word "VaiVarnaya" in this disease.[10]

It indicates that in

Pandu, colour of the body become changed i. e. discoloration.

Nirukti of Pandu Roga

According to Acharya Charaka[11]

This means, while describing the signs and symptoms of different types of Pandu, several

types of complexion like Harita (green) etc. are described. But all of these are dominated by

Panduta (Pale-Yellow colour) because of which this disease is called Pandu Roga.

Etymology of Anemia[12]

Origin of the word

Anemia is derived from the Greek word anemia which means “lack of blood”. The name

anemia accurately describes this condition as the individual experiences a reduced quantity of

red blood cells or hemoglobin which, in turn, causes pale skin.

Definition of Anemia

It is a deficiency of red blood cells and/or hemoglobin. This results in a reduced ability of

blood to transfer oxygen to the tissues, causing hypoxia; since all human cells depend on

oxygen for survival, varying degrees of anemia can have a wide range of clinical

consequences. Hemoglobin (the oxygen-carrying protein in the red blood cells) has to be

present to ensure adequate oxygenation of all body tissues and organs.

Definition:- Iron Deficiency Anemia

Anemia is a condition that results in a lowering of hemoglobin levels (Hb) below that is

considered to be normal for specific demographic group.[13]

In clinical terms Anemia is an



459


insufficient mass of red blood cells circulating in the blood; whereas in public health terms

Anemia is defined as a low hemoglobin concentration in blood, or less often, as a low

hematocrit, the percentage of blood volume that consists of red blood cells. Nutritional

Anemia are caused when there is an inadequate body store of a specific nutrient needed for

Hb synthesis. The most common nutrient deficiency is iron.[14]

Iron deficiency is defined as a

condition in which there are no mobilizable iron stores and in which signs of a compromised

supply of iron to tissues, including the erythron, are noted. Iron deficiency is ranked at the top

of three global ―hidden hungers (Iron, Iodine and Vit A: sub clinical deficiency without

visible signs of deficiency) with about one fifth of the world„s population is suffering from

iron deficiency Anemia.

Nidana (Etiological factors) of Pandu Roga[15]

Aharaj Nidana

Ksharatisevana (Excessive intake of Alkine substances), Amalatisevan (Excessive intake of

Saur substances, Lavanatisevana (Excessive intake of solty diet), Katukatisevana (Excessive

intake of pungent diet), Kasayatisevana (Excessive intake of Astrigent diet), Atiushnatisevana

(Excessive intake of Hot substances), Tikshanatisevana (Excessive intake of Sharp diet),

Rukshanatisevana, (Excessive intake of dry diet), Viruddhatisevana (Opposite diet),

Asatmyabhojana (Unwolsome diet), Nishpava, Mansadisevana (Meat), Tilanisevana

(Seasame), Tilatailanisevana (sesame oil), Vidagddhabhojana, Mrd bhakshanam (mud

eating), Vyapannasalilapanm, Vindya Prabhva salila Jalapanane, Pitta Stanypana,

Vishamsevanam.

Due to excessive intake of above substances have increased Pitta dosha and its vitiated Rasa

Dhatu and Alpa rakta utpati is create discoloration of skin.

Viharaja Nidana

Atinidra (Excessive sleep), Ativyayam (Excessive exercise), Ati Vyavaya (Excessive

intercourse), Atiayasa (Excessive work), Amatisarasamgraha, Bhaya (fear), Chinta

(Depression), Dushta Raktanigarha in Raktarsha (piles), Diwasvapana (day sleep), Krodha

(Anger), Kama, Ratrijagarana (awekning at night).

Rituvaishmya, Shoka, Snehavibhrma, Snehatiyoga, Vegavrodha, Vegavidharana in vamana

karma.



460


Diwaswapna, Avyayama leads to Ama formation and further Agni dushti which causes

improper Rasa Dhatu formation which further hampers the Rakta Dhatu formation and

leads to Pandu Roga.

According to Acharya Sushruta, Rakta gets vitiated by Diwaswapa, Viruddha Bhojana,

Krodha. He has also mentioned that Krodha, Shoka, Bhaya, Vidagdha Anna sevana, Ati

Maithuna and Tila Tail and Pinyaka leads to vitiation of Pitta Dosha.

Ativyayama, Ratrijagrana, Nidranasha, Ativyavaya and Ati Adhva gaman leads to Vata

Prakopa.

Chinta, Bhaya, Krodha, Shoka etc. Mansika Nidana also leads to Vata Prakopa and this

Vitiation of Vata Causes Agni dushti and improper Rasa Dhatu formation.

Acharya Charaka has emphasised bad effect of Chinta, Bhaya, etc on digestive process.

It creates agnimandhya (loss of digestive capacity) and ama formation (free radicles) leads to

srotorodha (obstruction in channels) and alpa rasa-rakta utpatti.

Nidanarthakara Roga

In Ayurvedic literature Pandu Roga has been indicated either as a symptom of any disease or

as upadrava rupa. So, all these diseases can be considered as Nidanarthakara Rogas of Pandu.

Some of whichare Raktarsha, Kaphaja Arsha, Raktarbuda etc.

Grahani, Jeerna Jwara, Katikataruna Marmavedhana, Kaphajarsha, Punravartaka Jwara,

Plihodara, Raktatiparvarta, Raktakshaya, Raktasrava, Vyavaya Shoshi, Raktarbuda,

Rasapradoshaja roga, Raktapradara, Sannipatodara, Shotha, Santrapanjanya roga, Upadrava

of Rakta Pitta, Vedha of Raktavahi dhamni, Yakrita plihavedha, Antarlohita.

Aetiology of Iron Deficiency Anemia

Dietary factors play an important role in the development of Iron Deficiency. Although most

habitual consumed diets in different regions of India contain adequate amount of Iron (26

mg/day), absorption of Iron From such diets is only 1.5%. Other factors that contribute to

Anemia are chronic blood loss due to hookworm infestation and malaria. In the vulnerable

segments of the population the increased demand due to the physiological status aggravates

the deficiency of Iron. The main causes of Iron Deficiency are.[16]

Poor absorption of Iron by the body.

Inadequate daily intake of Iron.



461


Severe blood loss due to heavy period or internal bleeding.

Increase demand of Iron during - pregnancy or childhood.

Anemia develops slowly after the normal stores of Iron have been depleted in the body

and in the bone marrow.

Gaucher Disease may also cause Anemia.

Iron Deficiency Anemia is always secondary to an underlying disorder. Correction of the

underlying causes, therefore, is essential part of its treatment following etiological factors is

involved in development of IDA at different age and sex.

(1) Females in reproductive period of life

The highest incidence of Iron Deficiency Anemia is in women during their reproductive

period of life. It may be from one or more of the following causes.

Blood loss

This is the most important cause of Anemia in women during child bearing age group.

Commonly, it is due to persistent and heavy menstrual blood loss such as occurs in various

pathological states and due to insertion of IUCDs young girls at the onset of menstruation

may develop mild Anemia due to blood loss. Significant blood loss may occur is a result of

repeated miscarriages.

Meat, poultry, fish, eggs, dairy products of Iron fortified foods are the best sources of Iron

found in food. Eating patterns that exclude these foods or food supplements may lead to

Iron Deficiency Anemia. Following a diet that has an imbalance of food groups also can

lead to this type of Anemia. Examples of diets that can lead to Iron Deficiency Anemia

include.

Low -Fat diets

Following a low fat diet over a long period of time may limit sources of Iron from animal

foods.

Diets high in Sugars

These types of diets are often low in Iron.

High-Fiber diets

These types of diets can slow the absorption of Iron.



462


Inadequate intake

Inadequate intake of Iron is prevalent in women of lower economic status. Besides diet

deficient in Iron, other factors such as anorexia, impaired absorption and diminished bio-

availability may act as contributory factors.

Increased Requirements - During pregnancy and adolescence, the demand of body for

Iron is increased. During a normal pregnancy, about 750mg. of Iron may be siphoned off

from mother about 400mg. to the fetus, 150mg to the placenta and 200 mg is lost at

parturition and lactation.

(2) Post menopausal Females

Though the physiological demand for iron decreases after cessation of menstruation. Iron

Deficiency Anemia may develop in post menopausal women due to chronic blood loss.

Among the important causes are.

- Post Menopausal uterine bleeding - due to carcinoma of the uterus.

- Bleeding from the alimentary tract such as due to carcinoma of stomach and large bowl and

hiatus hernia.

(3) Adult Males

It is common for adult males to develop Iron Deficiency Anemia in the presence of normal

dietary Iron content and Iron absorption. The vast majority of cases of Iron Deficiency

Anemia in adult males are due to chronic blood loss. The cause for chronic hemorrhage may

lie at one of the following sites.

- Gastrointestinal tract is the usual source of bleeding which may be due to Peptic Ulcer,

Hemorrhoids, Hook Worm Infestation, Carcinoma Stomach and Large Bowel, Esophageal

Varices, Hiatus Hernia, Chronic Aspirin Ingestion And Ulcerative Colitis. Other causes in the

GIT are mal-absorption and following gastrointestinal surgery.

- Urinary tract - e. g. due to hematuria and hemoglobinuria.

- Nose e.g. in repeated epistaxis.

- Lungs e. g. in hemoptysis from various causes.

(4) Infants and children

Iron Deficiency Anemia is fairly common during infancy and childhood with a peak

incidence at 1-2 yrs. of age. The principal cause for Anemia at this age is increased demand



463


of Iron which is not met by the inadequate intake of Iron in the diet. The normal full term

infant has sufficient Iron stores for the first 4-6 months of life, while premature infants have

inadequate reserves because Iron stores from the mother are mainly laid down during the last

trimester of pregnancy. Therefore unless the infant is given supplemental feeding of Iron or

Iron containing foods, Iron Deficiency Anemia develops. Periods of rapid growth or growth

spurts in children and teens are a good example of an increased need for Iron. If in these

period, children don't get enough Iron according to their requirement. They may develop

Iron Deficiency Anemia.

(5) Inability to absorb enough Iron from food

Certain factors make it hard for the body absorbs enough Iron from food. These factors

include Intestinal surgery i.e. partial or total gastrectomy.

Disease of the intestine - Such as:

Crohn's Disease.

Intestinal Malabsorption.

Achlorhydria

Low levels of folate, vita. B12 or Vita-C in the diet.

Prescription of medicines that reduces Iron absorption.

PURVARUPA (Premonitory Symptoms)

Symptoms which manifest themselves before the appearance of the disease are known as

Purvarupa. (Premonitory Symptoms).[17]

Avipaka, AkshikutaShotha, Aruchi, Alpavahnita, Angasada, Gatrasada, Hridspandaman,

Mutra Pitata, Mridbhakshanaechcha, Panduta, Rukshata, Swedabhava, Shrama,

Sthivanadhikya, Twakasphutana.

RUPA (Symptoms)

Vyakta Purvarupa is known as Rupa. Rupa appears in the Vyaktavastha i. e. fifth Kriyakala

of the disease. This is the unique stage of the illness, where it is clearly recognizable as all its

characteristic signs and symptoms manifest.



464


Samanya Rupa

All Acharyas have mentioned various types of discolouration with other symptoms in

different types of Pandu. Though, Acharya Charaka and Vagbhatta have mentioned the

Samanya Rupas of Pandu Roga.

Akshikutashotha, Aruchi, Arohaneayasa, Alpawaka, Annadwesha, Balakshaya, Bhrama,

Durbalya, Dhatugaurava, Dhatushithilya, Gatramarda, Gaurava, Hatanala, Hatprabhatva,

Jwara, Kopana, Karnashweda, Katiurupadaruka, Medalpata, Nidraluta, Nisharata,

Ojagunakshaya, Pindikodweshtana Panduta, Raktalpata, Shishiradwesha, Shwasa,

Shirnalomata, Sadana, Shrama, Shthivanadhikya, Shithilendriya.

Symptoms of Iron Deficiency Anemia

The onset of Iron Deficiency Anemia is generally slow. The usual symptoms are of

weakness, fatigue, dyspnoea on exertion, palpitations and pallor of the skin, mucus

membranes and sclera. Older patients may develop angina and Congestive cardiac failure.

Patients may have unusual dietary cravings such as pica. Menorrhagia is a common symptom

in Iron Deficient women.

Epithelial Tissue Changes

Long standing chronic Iron Deficiency Anemia causes epithelial tissue changes in some

patients. The changes occur in the nails is called koilonychias or spoon shaped nails.

Changes occur in tongue - Atrophic glossitis.

Changes occur in Mouth - Anuglar stomatitis.

Changes occur in oesophagus causing Dysphagia from development of thin membranous

webs at the post cricoid area which is referred to as plummer vinson syndrome.

Chronic case of Iron Deficiency Anemia also leads to Brittle Nail, Brittle hair.

Iron deficiency may also result in skin problems. In some patients pruritus (itching) may be

present. There may be also Dryness of the mouth and throat making it difficult to swallow

and hair becomes dry, brittle and dull. Increased hair shedding may be noticed.[18]

In mild case - Tiredness,

Fatigue,

Lassitude,

Shortness of breath



465


Decreased Muscular – endurance

Dizzinss.

In severe case -Oedema (usually occurs first in the feet and at the ankle)

Enlargement of heart

Tachycardia

Plummer - Vinson Syndrome

Chest pain.

Headache

Anemia, as well as producing the symptoms and signs discussed above, also leads to a

reduced ability to do heavy work for long periods.

Types of Pandu

Classification according to Acharya Charaka

Acharya Charaka has classified the Pandu Roga of 5 types. i.e

(1) Vataja Pandu Roga

(2) Pittaja Pandu Roga

(3) Kaphaja Pandu Roga

(4) Tridoshaja Pandu Roga

(5) Mridbhakshanaja Pandu Roga

Types of Anaemia[19]

1. Etiologic

This is classification by cause. An anaemia may be due to blood loss which may be due to

many causes, e.g. Excessive vaginal bleeding due to functional menorrhagia, malignancy or

endometriosis.

An etiologic classification is based on the various conditions that can result from any of the

physiologic changes and helps determine direction for planning care. A morphologic

classification provides an orderly method for ruling out certain diagnoses when establishing a

cause for a particular anaemia.

2. Pathophysiologic

Depending upon the patho physiologic mechanism anaemias are classified into three groups –

(1) Anaemia due to blood loss.



466


(2) Anaemia due to increased cell destruction.

(3) Anaemia due to increased red cell destruction.

(Haemolytic Anaemias)

(1) Anaemia due to blood loss

This is further of two types

a) Acute post haemorrhagic Anaemia

b) Anaemia of chronic blood cells.

(2) Anaemia due to impaired red cell production

A disturbance due to impaired red cell production from various causes may produce

Anaemia. These are as under:

a) Cytoplasmic maturation defects

- Deficient haem synthesis: Iron Deficiency Anaemia

- Deficient globin Synthesis: Thalassemic syndromes

b) Nuclear maturation defects

- Vitamin B12 and/or folic and deficiency

- Megaloblastic Anaemia

c) Haematopoietic stem cell, proliferation and differentiation abnormalities e. g.

- Aplastic Anaemia

- Pure red cell aplasia

d) Bone marrow failure due to systemic diseases (Anaemia of chronic disorders) e. g.

- Anaemia of inflammation/infections disseminated malignancy.

- Anaemia in renal disease.

- Anaemia due to endocrine and nutritional deficiency (Hypo metabolic states)

e) Bone marrow infiltaration e. g.

- Leukaemias

- Lymphomas

- Myelosclerosis

- Multiple Myeloma

f) Congenital Anaemia e. g.

- Sideroblastic Anaemia

- Congenital dys erythropoietic



467


(3) Anaemia due to increased red cell destruction

(Haemolytic Anaemia)

This is further divided into 2 groups.

-Intra corpuscular defect (Intrinsic red cell abnormalities)

It may be either hereditary or acquired.

-Extra corpuscular defect (Acquired haemolytic Anaemia).

3. Morphologic

This is a classification based on cell size and color. This classification is usually used in the

laboratory as we actually see the cells. It is not entirely satisfactory as an anaemia due to

chronic bleeding may be normocytic at one point, microcytic later and microcytic

hypochromic even later. In fact the most often used classification system is a combination of

the pathophysiologic and morphologic. Such morphologic changes in the red blood cell are

described in this manner.

Cell size

Terms that refer to cellular size end with "cytic".

Normocytes (Normal)

Microcytes (Smaller than normal)

Macrocytes (Larger than normal)

Anisocytes (Various sizes)

Cell shape

Poikilocytes (Irregularly-shaped cells)

Spherocytes (Globular cells)

Drepanocytes (Sickle cells)

Cell color

Generally refers to the staining characteristic which reflects the haemoglobin concentration.

Terms that describe haemoglobin content end with "chromic.”

1. Normochromic (Sufficient or normal amounts of haemoglobin)

2. Hyperchromic (Containing an unusually high concentration of haemoglobin in its

cytoplasm)



468


3. Hypochromic (Containing an ab`normally low concentration of haemoglobin)

These changes produce the following categories of anaemias:

Macrocytic anaemias

Microcytic-hypochromic anaemias

Normocytic-normochromic anaemias.

(1) Macrocytic Anaemia

In this type of Anaemia, MCV is raised e. g. in megaloblastic Anaemia due to deficiency of

Vitamin B12 or folic acid. Megaloblastic Anaemia is the most common cause of macrocytic

anaemia. It also known as megaloblastic anaemia produces large, abnormally shaped

erythrocytes but normal haemoglobin concentrations.

The macrocytic anaemias may be further subdivided based upon the degree to which the

MCV is raised and the presence of megaloblastic production in the bone marrow.

Slight increase in MCV

CV >100 and <105 fl

- In some instances of aplastic anaemia

- Myxedema.

In all cases the red cell precursors in the marrow are normal in morphology.

Moderate increase in the MCV

MCV >105 and <110 fl In liver disease.

Marked increase in the MCV

MCV > 110 fl Megaloblastic due to the lack of vit. B12 Or folic acid.

Macrocytic Anaemia can be further divided into “Megaloblastic Anaemia” and Non-

Megaloblastic Macrocytic. The cause of the Megaloblastic Anaemia is primarily a failure of

DNA synthesis, which results in restricted cell division of the progniter cells. The Non

Megaloblastic Macrocytic Anaemia has different etiologies. i. e. there is unimpaired DNA

synthesis, which occur for example in alcoholism.



469


Megaloblastic Anaemia

Deficiency of vitamin B-12

Deficiency of folic acid

Drugs affecting DNA synthesis

Inherited disorders of DNA synthesis

Nonmegaloblastic bone marrow

Liver disease

Hypothyroidism and hypopituitarism

Accelerated erythropoiesis (reticulocytes)

Hypoplastic and aplastic anaemia

Infiltrated bone marrow

(2) Microcytic-hypochromic anaemia

It produces small, abnormally small erythrocytes and reduced haemoglobin concentrations.

However, hypochromia can occur even in cells of normal size. This type of anaemia results

from a variety of conditions that are caused by disorders of iron metabolism, porphyrin and

heme synthesis, or globin synthesis.

In Microcytic anaemia, the red blood cells (erythrocytes) are usually also hypochromic,

meaning that the red blood cells are paler than usual. This can be quantified as the mean

corpuscular haemoglobin or mean cell haemoglobin (MCH), the amount of haemoglobin per

cell; the normal value is 27-32 picograms (pg). Similar is the mean corpuscular haemoglobin

concentration or mean cell haemoglobin concentration (MCHC), giving the amount of

haemoglobin per volume of erythrocytes (normally about 320-360 g/l or 32-36 g/dl).

Typically, therefore, anaemia of this category is described as "microcytic, hypochromic

anaemia".

Microcytic Anaemia is primarily a result of haemoglobin synthesis failure/insufficiency,

which could be caused by several etiologies.

Heme Synthesis Defect

Iron Deficiency

Anaemia of chronic disorders.



470


Globin Synthesis defect

Alpha and beta Thalassemia

HbE syndrome

HbC syndrome.

Sideroblastic defect

Herediatary Sideroblastic Anaemia

Acquired

Reversible

(3) Normocytic-normochromic Anaemia

These are due to either an increased rate of red cell destruction or a failure in red cell

production. The presence of specific poikilocytes is often diagnostic. It produces a

destruction or depletion of normal or mature erythrocytes. Although the erythrocytes are

relatively normal in size and in haemoglobin content, they are insufficient in number. In this,

MCV, MCH, MCHC are all normal.

This type does not share any common cause, pathologic mechanism, or morphologic

characteristics and is less common than the others.

Normocytic anaemia occurs when the overall Hb levels are decreased, but the red blood cell

size (MCV) remains normal. Causes include.

Acute blood loss

Anaemia of chronic disease

Aplastic anaemia (bone marrow failure)

Hemolytic anaemia

Some types of anaemia include the following:

SAMPRAPTI (Pathogenesis)

In general, Samprapti means development of the disease, which includes the sequences of

process or events from Nidana Sevana to the characteristic development of disease.

Acharya Charaka has clearly described the Samprapti of Pandu. According to him, Due to

Nidana Sevana; Pitta located in the Hridaya gets aggravated and this Pitta being forcefully

propelled by Vayu enters into the 10 vessels (attached to the heart) and circulates in the entire


http://en.wikipedia.org/wiki/MCV

http://en.wikipedia.org/wiki/Hemorrhage

http://en.wikipedia.org/wiki/Anemia_of_chronic_disease

http://en.wikipedia.org/wiki/Aplastic_anemia

http://en.wikipedia.org/wiki/Hemolytic_anemia


471


body. Being located between the skin and muscle tissue, this aggravated Pitta Vitiates Kapha,

Vayu, Asrika, Twacha and Mamsa as a result of which different types of colouration, like

Pandu, Haridra and Harita appear in the skin.

Role of Dosha in Pandu

Role of Vata Dosha

Though Pitta is pradhana dosha in Pandu roga, vata dosha also plays an important role in

manifestation of pandu roga. Vitiated vata is responsible for kampa, angasada, gatrashula,

raukshya, twaka parushya, kati-uru-pada ruka etc.

Role of Pitta Dosha

Pitta is responsible for the normal colour of body but when it vitiates the Rakta, as it happens

in Pandu roga the loss of complexion or Panduta occurs.

Role of Kapha Dosha

Kapha seems to play a vital role in the development of Panduta. According to Acharya

Charaka, any person in whom there is a depletion of vata develops the panduta due to the

combined action of Pitta and Kapha.

It has also been stated that santarpan which broadly means anabolism, brings about an

increase in Kapha which in term may cause the disease by generating Ama and causing

mandagni. Thus, any diet which may increase kapha or any disease associated with increase

in kapha can cause a change in complexion of Panduta. Vitiation of Kapha is responsible for

Gaurava, Nidraluta, Mandagni, Alasya, Alpawaka etc.

Role of Dushyas in Pandu Roga

Acharya Charaka and Vagbhatta implicate Twacha, Rakta and Mamsa as the dominant

dushyas vitiated in Pandu roga.

Symptoms

Rasadhatu dushti:- Aruchi, Jwara, Panduta, Gaurava and Tandra, Karshya, Angamarda.

Raktadhatu dushti:- Panduta, Daurbalya, Akshikutshotha, Swasa, Hridspandana.

Twak, Mamsa and Medodhatu dushti:- Atisweda and Swedabhava.

Majja dhatu dushti:- Bhrama, Murchha and Tamasa Darshana.

Ojo vyapat:- Guruta, Varna bheda and Nidra are suggestive of Ojo vyapat.

Asthidhatu dushti:- Shiranalomata.



472


Pathogenesis of Iron Deficiency Anaemia[20]

In the human body, Iron is present in all cells and has several vital functions as a carrier of

oxygen to the tissues from the lungs in the form of hemoglobin as a facilitator of oxygen use

and storage in the muscles as Myoglobin as a transport medium for electrons within the cells

in the form of cytochromes and as an integral part of enzyme reactions in various tissues. Too

little iron in the body can interfere with these vital functions and lead to morbidity and

mortality.

Iron Deficiency Anemia develops when the supply of Iron is inadequate for the requirement

of hemoglobin synthesis. Usually, this happens slowly over a period of time.

Most often, the person is not taking in enough iron to meet the needs of the body. Next, the

body starts to use iron that it has stored. When the stored iron is used up, new red blood cells

have less hemoglobin than normal, and fewer red blood cell are produced. Finally, when the

number of red cells is too low, iron-deficiency Anemia develops. The development of Iron

Deficiency Anemia depends upon one or more of the following factors.

(1) Increased blood loss.

(2) Increased requirements.

(3) Inadequate dietary intake.

(4) Decreased intestinal absorption.

The relative significance of these factors varies with the age and sex of the patients.

Accordingly, certain groups of individuals at increased risk of developing Iron Deficiency. In

general, in developed countries the mechanism of Iron Deficiency is usually due to chronic

occult blood loss, while in the underdeveloped countries poor intakes of Iron or defective

absorption are responsible for Iron Deficiency Anemia.

Stages of IDA

The terms Anemia, Iron Deficiency and Iron Deficiency Anemia often are used

interchangeably but equivalent. Iron deficiency ranges from depleted iron stores without

functional or health impairment to iron deficiency with Anemia, which affects the

functioning of several organ systems.[2]

Iron Deficiency Anemia is the condition in which

there is Anemia and clear evidence of Iron Deficiency. However, Iron Deficiency occurs in

steps.



473


These can be divided in three stages

(1) Negative Iron Balance.

(2) Iron Deficient Erythropoiesis.

(3) Iron Deficiency Anemia.

Negative Iron Balance

The first stage is Negative Iron Balance, in which the demands for (or losses of) iron exceeds

the body's ability to absorb iron from the diet. This stage can result from a number of

physiological mechanisms including Diseases.

Blood loss

Pregnancy (In which the demand for red cell production by the fetus outstrip the mother's

ability to provide Iron)

Rapid growth spurts in the adolescent.

Inadequate dietary Iron Intake.

Most commonly, the growth needs of the fetus or rapidly growing child exceed the

individual's ability to absorb the Iron necessary for hemoglobin synthesis from the diet. Blood

loss in excess of 10-20 ml of red cells per day is greater than the amount of Iron that the gut

can absorb from a normal diet. Under these circumstances the iron deficit must be made up

by mobilization of Iron from the storage site. During this period measurements of Iron stores.

- Such as the serum ferritin level or the appearance of stainable Iron on bone marrow

desperation will decrease. As long as Iron stores are present and can be mobilized the serum

Iron Total Iron Binding Capacity (TIBC) and red cell protoporphyrin levels remain within

normal level. At this stage, red cell morphology and indices are normal.

Iron Deficient Erythropoiesis

When Iron stores become depleted, the serum iron begins to fall. In iron depletion stage, the

amount of stored iron (e.g., as measured by serum ferritin concentration) is reduced but the

amount of functional iron may not be affected.

Gradually, the TIBC increases, as do red cell protoporphyrine level. By definition, marrow

Iron stores are absent when the serum ferritin level is 15 < μg/dl. As long as the serum Iron

remains within the normal range, hemoglobin synthesis is unaffected despite the dwindling

Iron stores. Once the transferrin saturation falls to 15 to 20% hemoglobin synthesis becomes



474


impaired. This is a period of evaluation of the peripheral blood smear reveals the first

appearance of microcytic cells and if the laboratory technology is available. One finds

hypochromic reticulocytes in circulation.

Iron Deficiency Anemia

Gradually, the hemoglobin and hematocrit begin to fall reflecting Iron Deficiency Anemia.

The transferrin saturation at this point is 10 to 15%. When moderate Anemia is present

(hemoglobin: 10-13g/dl), the bone marrow remains hypoproliferative with more severe

Anemia. (hemoglobin: 7- 8g/dl) hypochromia and microcytosis become more prominent

misshapen red cells. (Poikilocytes) appear on the blood smear as cigar or pencil shaped forms

and target cells and the erythroid marrow becomes increasingly ineffective.

Comparision of Pandu Roga with Anemia on the basis of Nidana

In Ayurvedic text Nidana can be broadly classified into 3 categories:

1. Aaharaja Nidana

2. Viharaja Nidana

3. Manasika Nidana

Aaharaja Nidana

It includes excessive intake of ushana, lavana, alma, katu rasa, virudhabhojana,

vidagdhabhojana, asatmyabhojana. Similarly in Modern science, the acid-creating foods,

sugar sweetened sodas, most desserts, snack foods such as potato chips, etc. All are

considered in low nutrient foods as well they impair the digestion & affect the absorption of

various nutrients including Iron. These can also cause injury to the intestinal mucosa which

further decreases the absorption of nutrients.

Viharaja Nidana

It includes excessive vyayama, diwaswapa & vegavidharana etc. According to modern

science, these are considered as important factor for Iron Deficiency Anemia. Day sleep

during digestion as well as excess intake of dry foods decreases the rate of metabolism. The

paucity in digestion is reported to be a cause in the decreased absorption of essential nutrients

including Iron.



475


Manasika Nidana

It includes Chinta, Shoka, Krodha, Bhaya etc. psychological factors, which impairs digestion,

deteriorate the general health, thus leading cause for many diseases, including Anemia.

Moreover, In Ayurvedic classics, grahani has been described as one of the etiologic factors of

Pandu roga. In grahani, there is malabsorption of nutrients. Same thing has also been

considered in modern science that, due to malabsorption there is impaired absorption of Iron

causing Iron Deficiency Anemia.

On the basis of Sign & Symptoms

There is striking similarity between the description of Pandu roga in Ayurvedic text &

Modern science which is described as below.

Alpa Rakta - Lack of blood

Alpa Meda- Emaciation

Nihsara- lusterless

Shithilendriya- Hampered physical and intellect functions

Jwara- Fever

Bhrama- Giddiness

Aruchi- Anorexia

Karnkshweda- Tinnitus

Daurbalya- Weakness

Pindikodveshtana- Calf muscle cramp

Kati-uru-pada-ruk- Pain in joints

Arohane-ayasa- Exertional dyspnoea

Kopanatva- Irritability

Chikitsa

All the available Ayurvedic Texts envisage the management of Pandu which can be classified

under two headlines.

(1) Chikitsasutra which refers to the principles of Pandu Roga in general. They are Snehan,

Shodhana (Vamana, Virechana) Aaushadhisevan.

(2) Different Remedies for Pandu.



476


Line of treatment of Pandu Roga[21]

Line of treatment in General

The patient suffering from Pandu Roga should be given emetic and purgative drugs for the

shodhana of the body by the elimination of Doshas. After Shodhana, patient should be given

wholesome food containing.

Old shali type of rice, Yava, Godhuma Mixed with the Yusha of mudga, Adhaki and

Masura.

Mamsa Rasa of Jangala Animals.

After that, specific medicines on the basis of the aggravated Doshas should be

administered.

Ghrita for Shehana

For the purpose of oleation, the patient suffering from Pandu should be given Panchagavya

Ghrita, Maha Tikta Ghrita and Kalyanaka Ghrita.

Most suitable Drugs for Vamana Karma

Acharya Charaka has mentioned “Krutavedhana” for Vamana Karma in case of Pandu.

Most suitable Drugs for Virechana Karma

Virechana Yoga in General

o After the patient is properly oleated, he should be given purgation therapy frequently with

the following recipes.

o Milk added with cow‟s urine.

o Milk alone.

o Luke-warm infusion of Danti, Sprinkled with the powder of one anjali of fruit of

Gambhari or infusion of Danti with paste of one anjali of Draksha.

Virechana Yoga for specific types of Pandu

Virechana Yoga for Paitika type of Pandu

The patient suffering from paittika type of Pandu Roga should take half pala of the powder of

Trivrita mixed with one pala of sugar.

Virechana Yoga for Kaphaja type of Pandu

The patient suffering from Kaphaja type of Pandu Roga should take Haritaki impregnated

with cow‟s urine.



477


o Snuhi Kshira

o As per Acharya Vagbhatta, patient should keep on a medicament consisting of only milk

and cow‟s urine together for a period of 15 days.

Line of Treatment in specific types of Pandu

For Vatika Type of Pandu, the therapy should be dominated by Sneha Dravya, for Paittika

Pandu, it should be dominated by bitter and cooling drugs, for Kaphaja type of Pandu, the

therapy should be dominated by Katu, Ruksha and Ushna drugs & for Sannipatika Type of

Pandu, all the above mentioned ingredients should be combined. Means, depending upon the

Doshas, different types of treatment should be given to the patient suffering from Mrid-

Bhakshanaja Pandu.

Different remedies for Pandu

1. Herbal Products:- Guduchi, Pippali, Haridra etc.

2. Mineral Products:- Lauha, Mandoor, Makshika, Gairika, Shilajita etc.

3. Animal Products:- Pravala, Mukta, Shankha, Anjana, Takra, Gomutra, Ajasakr.

YOGA

VATI: - Mandoor Vataka, Punarnava Mandura, Shilajatu Vatak, Kutajadi

Vataka, Bibhitakadi Vataka, Panchanana Vatika, Laghushiva Gutika

CHURNA:- Navayasa Churna, Ajasakritadi churna, Khandasamaka churna

GHRITA:- Katukadhya Ghrita, Pathya Ghrita Danti Ghrita, Draksh Ghrita, Haridradi Ghrita,

Dadimadhya Ghrita, Brihatyadi Ghrita

ASAVA ARISTA:- Lauhasava, Manduarista, Dhatrayarista, Bijakaris, Gaudarista

AVALEHA:- Daryadi Leha, Dhatri Avaleha, Vidangadhya

APPROACHES TO CONTROL IRON DEFICIENCY ANAEMIA[22]

(A) Food based approaches

� Dietary improvement

� Food fortification

� Emergency food

� Food aid

(B) Iron supplementation

Foods which contain Heme iron



478


Heme iron is found only in animal foods and easily absorbed by the body:

Meat, Egg yolks, Fish, Oysters, Shellfish, Poultry “The redder the meat the higher the

Iron content.”

Foods which contain Non Heme iron

Non heme iron is found in plant foods and is not as readily absorbed as heme iron due to

following inhibiting factors, i.e. Phosphoric Acid, Phytic Acid, Oxalic Acid, Tannic Acid etc.

Dark green leafy vegetables i. e. spinach etc., Soup of green gram, Unpolished rice Wheat,

Garlic, Unripe and ripe bananas, Ripe mango, Apple, Pomegranate, Soya Product, Rhuburb,

Plum, Almond, Apricot, Eggs, Strawberry, Raisin, Carrot, Fig etc.

Oral Therapy

In the patient with established IDA who is asymptomatic, t/t with oral iron is usually

adequate. Multiple preparations are available ranging from simple iron salts to complex iron

compounds designed for the sustained release throughout the small intestine. Some

preparations come with other compounds designed to enhance iron absorption, such as citric

acid.

Elemental iron content of various oral iron preparations

Preparation Amount (mg) Ferrous iron (mg)

Ferrous fumarate 200 65

Ferrous gluconate 300 35

Ferrous succinate 100 35

Ferrous sulphate 300 60

Ferrous sulphate (dried) 100 65

REFERENCES

1. Charak Samhita Chi. Ch. 16, Edited by Prof. Priyavarat Sharma. Sushrut Samhita Uttar

tantra.ch. 44. Edited with Ayurveda tattva Sandipika by Kaviraj Ambikadutta Shastri,

Reprint – 2005 Published by Chaukhambha Sanskrita Sansthana Varanasi.

2. Harmening DM. Clinical hematology and fundamentals of hemostasis. In Anemia

Diagnosis and clinical considerations, 3rd

ed. Philadelphia: FA Davis Company. 1997.

3. WHO. Turning the tide of malnutrition: responding to the challenge of the 21st

century

Geneva WHO, 2000 (WHO/NHD. 007).

4. www. who int/nutrition (topics/ida/en).

5. www. ncbi. nlm. nih. Gov/p.



479


6. Amarakosha Pu. Kha. 5/13 II edition 1976.

7. Vachaspatyam Tarka Vachaspati Shree Taranath Bhattacharya Vol.1 to 5, Chaukhambha

Sanskrit Series Office, 1962.

8. Gadnigraha- Written by Shree Vaidhya Shodhala with the “Vidyotini” Hindi

Commentary by Shree Indradeva Tripathi. Edited by – Shree Ganga Sahay Pandeya. 3rd

Edition, 1999. Published by Chaukhambha Sanskrit Sansthana, Varanasi.

9. Sanskrit English Dictionary – By Sir M. Monier William, Page 616.

10. Cha. Chi. 16/5.

11. Cha. Chi 16/6.

12. The Concise Oxford Dictionary of English Etymology: 1996, Author: T. F. HOAD.

13. Ibid 16, (A) Gillespie S, editor. Malnutrition in South Asia-A regional profile. S l:

UNICEF Regional office for South Asia (ROSA); 1997. PublicationNo.5/1997.

14. Ibid 16, (B) A review of the efficacy and effectiveness of nutrition interventions

ACC/SCN. Nutrition policy paper no.19. Asian Development Bank Nutrition and

Development series No.5/2001.

15. Ch.Chi.16/1.

16. Harsh Mohan- Text book of Pathology (5th

edition).

17. Cha.Ni.1/8.

18. (a) Harsh Mohan- Text book of Pathology (5th

edition), pg 356.

(b) Book: Textbook of Dermatology. Ed Rook A, Wilkinson DS, Ebling FJB, Champion RH,

Burton JL. Fourth edition, Blackwell Scientific Publication.

19. Stamatoyannopoulos G, Majerus PW, Perimutter RM. The Molecular Basis of Blood

Diseases. Philadelphia, Pa: WB Saunders Co; 2000.

20. (a) Harsh Mohan- Text book of Pathology (5th

edition), pp 370.

(b) Akman M, Cebeci D, Okur V, Angin H, Abali O, Akman AC. The effects of iron

deficiency on infants' developmental test performance. Acta Paediatr., 2004 Oct; 93(10):

1391–6.

©Harrison‟s - Internal Medicine (16th

edition), 1: 588.

21. Charak Samhita Chi. Ch. 16/40-42, Edited by Prof. Priyavarat Sharma Reprint – 2005

Published by Chaukhambha Sanskrita Sansthana Varanasi. Pg .No.275,276.

22. (a) Cutler P. Deferoxamine therapy in high-ferritin diabetes. Diabetes, 1989; 38:

1207–10.



480


(b) Olivares M, Pizarro F, Pineda O, Name JJ, Hertrampf E, Walter T. (Jul 1997). "Milk

inhibits and ascorbic acid favors ferrous bis-glycine chelate bioavailability in humans". J

Nutr, 127(7): 1407-11. PMID 9202099.


Date post:	04-Jan-2017
Category:	Documents
Upload:	phamdang
View:	225 times
Download:	0 times

review article: on pandu wsr to iron deficiency anemia

Documents