A COMPARATIVE STUDY TO INVESTIGATE THE EFFECT OF VAMANA KARMA AND TRIPHALA AND GUDUCHI CHURNA WITH MADHU ON GUT MICROBIOTA AND METABOLITE PATTERNS IN PRAMEHA W.S.R TO TYPE 2 DIABETES MELLITUS AND HEALTHY INDIVIDUALS.

This is a comparative study to investigate the effect of Vamana Karma and Triphala Churna and Guduchi Churna with Madhu on the gut microbiota and metabolite patterns in Prameha W.S.R to Type 2 Diabetes Mellitus and Healthy Individuals as well as to compare the effect of Vamana Karma followed by administration of Triphala Churna and Guduchi Churna with Madhu and administration of Only Triphala Churna and Guduchi Churna with Madhu  in the patients of Prameha W.S.R Type 2 Diabetes Mellitus.

Diet and lifestyle modification being an integral part of Vamana Karma(therapeutic emesis for internal bio-cleansing) may lead to the modification of environmental microflora in a positive aspect for shaping the healthy human microbiota composition thus leading to the state of wellness. This whole information gives a lead that Vamana therapy aims at modulating the gut functioning and thereby restoring the state of homeostasis, improving digestion and metabolism in turn proved to be an effective treatment modality in many diseased conditions like Rheumatoid arthritis, skin disease, Type 2 diabetes mellitus, allergic conditions etc. Therefore, this study can investigate the role of classical Vamanatherapy as described in Ayurveda by showing its impact in the modulation of dysbiosis and hence it can emerge as a proven modality of treatment in variety of metabolic, immune mediated, neuropsychiatric and musculo-skeletal diseased conditions.

The study contains the following three groups-

1. Group 1-PramehaPatients (Vamana Karma followed by TriphalaandGuduchi Churnawith madhu)- 15 subjects
2. Group 2- PramehaPatients (Administration of only Triphalaand Guduchi Churnawith madhu)- 15 subjects
3. Group 3 - Healthy Individuals (Vamana Karma followed by Triphala and Guduchi Churnawith madhu)- 15 subjects

The above mentioned three groups have been taken with an objective to compare the effect of Vamana Karma followed by Triphala Churna and Guduchi Churna with Madhu and administration of only Triphala Churna and Guduchi Churna with Madhu in the patients of Prameha W.S.R to Type 2 Diabetes Mellitus with respect to change in Sign and symptoms, Plasma Glucose Level and gut Microbiota and metabolite patterns i.e Group 1 and Group 2.

It will also compare the alterations being seen on the gut microbiota and metabolite patterns in both the Prameha and Healthy Individuals undergoing Vamana Karma followed by administration of Triphala and Guduchi churna with Madhu i.e Group 1 and Group 3.

RESEARCH QUESTION

• Is there any difference in the efficacy of Vamana Karma followed by TriphalaandGuduchi Churna with Madhu and direct administration of Triphalaand Guduchi Churna with Madhu in the management of Prameha(T2DM).
• Is there any difference in the impact of classical Vamana Karmafollowed by TriphalaandGuduchi Churna with Madhu on the alteration of Gut Microbiota diversity and metabolite patterns in the patients of Prameha(T2DM) and healthy individuals as well as in the administration of direct Triphalaand Guduchi Churna with Madhu in the patients of Prameha(T2DM) only.

HYPOTHESIS

There is significant difference in the efficacy of Vamana Karmafollowed by Triphalaand Guduchi ChurnawithMadhuas compared to direct administration of Triphalaand Guduchi ChurnawithMadhu in the management of Prameha.

There is significant difference in the impact of classical Vamana karmafollowed by Triphalaand Guduchi ChurnawithMadhuon the alteration of Gut Microbiota diversity and metabolite patterns in the patients of Prameha(T2DM) and healthy individuals as well as in the administration of direct Triphalaand Guduchi ChurnawithMadhu in the patients of Prameha(T2DM) only.

OBJECTIVES OF THE RESEARCH PROJECT**:**

PRIMARY:

1. To compare the efficacy of Vamana Karma followed by administration of Triphalaand Guduchi ChurnawithMadhu and administration of only Triphalaand Guduchi ChurnawithMadhu in the management of Prameha(w.s.r to T2 DM).
2. To see the impact of Classical Vamana karma followed by administration of Triphalaand Guduchi ChurnawithMadhu on gut microbiota diversity and metabolite patterns in Prameha (w.s.r Type 2 Diabetes).

SECONDARY:

1. Whole microbiome and metabolome Analysis of both Prameha and healthy individuals to see the impact of classical Vamana karma on Gut Microbiome and metabolomes.
2. To evaluate change in Plasma Glucose level in the patients of Prameha (w.s.r T2 DM).
3. To improve the quality of life.

METHODOLOGY-

TYPE OF STUDY DESIGN

• Experimental Study
• Triple armed controlled clinical trial.

SAMPLE SIZE CALCULATION

This type of study is being done first time and further the experimental procedures and tests are costly. Therefore, seeing the feasibility we have decided to take 15 individuals in each group.

1. Group 1- PramehaPatients- (Vamana Karma followed by TriphalaandGuduchi Churnawith madhu)- 15 Subjects
2. Group 2- PramehaPatients(Administration of only Triphalaand Guduchi Churnawith madhu)- 15 Subjects
3. Group 3-Healthy Individuals (Vamana Karma followed by Triphala and Guduchi Churnawith madhu)- 15 Subjects

Total Sample Size = 45

SAMPLE COLLECTION -

Cases (group 1 and group 2) will be recruited attending the OPD& IPD of AIIA, fulfilling the diagnostic criteria as per WHO latest guidelines for T2DM and Clinical Proforma for madhumeha(T2DM) of CSIR Ayurgenomics Unit- TRISUTRA CSIR-IGIB, NEW DELHI

The subjects will be allocated to above 2 groups by randomisation. The 30 random numbers will be picked from random number table. The odd numbers will be allocated to Group A and even numbers to Group B and will receive their respective treatments.

Controls (group 3) will be recruited as per Proforma for Health Assessment by self-reporting  and Prakriti Assessment Proforma of CSIR Ayurgenomics Unit- TRISUTRA CSIR-IGIB, NEW DELHI.

DRUG DELIVERY REGIMEN (DRUG, DOSE DURATION, FOLLOW-UP, WITHDRAWAL)

In Group 1 and 3-

Stepwise administration of-

1.Deepana-Pachana

• Shunthi churna - 3gm BiD
• Nagarmotha churna -  3gm BiD

For 3-7 Days until samyaka langhana lakshanas are observed

2. Snehapana-

Murchita-Goghritam (Aarohana krama i.e in increasing dose starting from 40 ml)

For 3-7 days until samyaka snigdha lakshanas are observed

3. Abhayangam–

With Tila Taila (Q.S)- For 30-35 minutes

For 1 Days and on the day of Vamana

4. Swedanam

Dashmulakwath sarvang mridu bashpa sweda(whole body sudation with Dashmula kwath till samyak swinna lakshanas are observed)

For 1 Days and on the day of Vamana

5. Vamana

1. **Madanaphala-phala-pippali churna= 6gm(Antarnakhmushti pramana)Soaked in Yashtimadhu kashayaovernight
2. Saindhav = 2.5gm
3. Madhu = Q.S
4. Yashti Kashaya = 150ml

After aakantha-yavagu-pana/dugdhapana(complete filling of stomach with gruel or milk)

For a single time and day

6. Samsarjan karma

A systematised and gradual administration of wholesome diet plan

For 3-7 days depending upon Vamana vega(frequency of purgations).

7. Oral Administration of TriphalaandGuduchi ChurnawithMadhu

• Triphala Churna(3gm) mixed with madhu(3gm) - BiD (before food)
• Guduchi Churna(3gm) mixed with madhu(3gm) – BiD (after food)

For 15 days

In Group 2

• Oral Administration of TriphalaandGuduchi ChurnawithMadhu

1. Triphala Churna(3gm) mixed with madhu(3gm) - BiD (before food)
2. Guduchi Churna(3gm) mixed with madhu(3gm) – BiD (after food)

For 30 days

Total no. of Days treatment given

Total number of days for Group 1 and Group 3 (with an average of Deepana-Pachana , Snehana , Abhyanga, Swedana, Vamanaand Samsarjan krama is 11-23 Days ) + (Triphala-Guduchi Churnawith madhu â€“ 15 days) = Between 26-38 days

In Group 2

• Oral Administration of Triphalaand Guduchi Churna: for 30 days

Total number of days for Group 2 = 30 Days

Follow-up Period**-**

At 15th day and 30th day after completion of treatment

PARAMETER FOR ASSESSMENT OF STUDY OUTCOMES

• Reduction in Sign and Symptoms of Prameha(T2DM)patients(By questionnaire Scoring Pattern).
• Microbiota and metabolite analysis of faecal matter, oral swab and vomitus sample through 16s rRNA technology.
• Plasma Glucose level through intravenous blood sample of the patients.
• QOL Questionnaire

Collection of specimens

• Faecal Sample
• Oral swab
• Vomitus sample*
• Blood Sample*

*Note- Vomitus and Blood sample(for molecular analysis simultaneously along with the blood sample to be collected for Plasma Glucose level test) will also be collected for future analysis if resources and time would allow.

RESPONSE CALCULATION AND ASSESSMENT OF RESPONSE:

The primary outcome measure of this study is to determine the response (R) of the patients to the therapy and it is proposed to be measured in terms of the -

• Reduction in sign and symptoms of prameha and plasma glucose levels.
• Absence/reduction in the microbiota and metabolites associated with Type 2 Diabetes Mellitus and which are not beneficial for metabolism.
• Presence/increase in microbiota and metabolites helping in the prevention of T2DM and which are beneficial for metabolism.