Management of Hypertriglyceridemia with Virechana Karma: A Case Report

Introduction

Hypertriglyceridemia refers to a fasting plasma triglyceride measurement that is increased up to 160 ml/ dL (1.7 mmol/L) or above.1 It is the most common form of dyslipidemia observed in the general population. Familial tendency, metabolic syndrome, certain drugs and dietary causes are some of the common etiological factors. People with hypertriglyceridemia are frequently obese, insulin resistant, hypertensive or diabetic, all of which are risk factors for cardiovascular disease.2,3

Based on severity, hypertriglyceridemia can be moderate (150-499 mg/dL) or severe (> 500 mg/dL).4 Addressing the secondary factors, dietary changes and use of statins form the management protocol in case of hypertriglyceridemia for prevention of further complications like pancreatitis and atherosclerotic cardiovascular diseases.3

Agni is an important component which is responsible for converting the Panchabhutatmaka Ahara into Dhatus. This Ahara is divided in to Saara and Kitta Bhaga of Dhatus by the action of respective Dhatwagnis. Any alteration from the normal in production of Medas by Medo Dhatwagni leads to Medoroga or Sthoulya. 5 Santarpana Janya Hetus like Ati Madhura, Ati Snigdha Ahara, Avyayama, Atyasana6 etc lead to vitiation of Jatharagni and production of Ama. This Jatharagni Dushti and Ama cause Medo Dhatwagnimandya which further leads to formation of Ama Asthayi Medas (hyperlipidemia) alone or together with Sthayi Meda Dhatu (obesity). The Ama Asthayi Medo Dhatu, if left untreated, on further vitiation leads to Margavarodhajanya Vataprakopa leading to Shoshana and Kathinya of Sthanika Medo Dhatu. This results in a condition termed as Dhamani Pratichyaya which is a Kapha Nanatmaja Vikara. 7 Hence, correction of Agni and Strotoshodhana will help to establish normal lipid metabolism. Virechana, a type of Shodhana Langhana is indicated in Santarpanottha Vikaras. 8,9 It is the main Upakrama of Pitta dosha whose main site is Grahani. Hence understanding its action on Agni and Koshta helps in reversing the pathogenesis from Agni to Dhatwagni and eventually the Saara Dhatu formation.

Case report

A female patient aged 49 years (OPD No.- 293515), who was a known hypertensive since eight years with no specific complaints was advised lipid profile in her routine annual blood screening. She was found to have highly elevated Serum Triglyceride levels (770.0 mg/dL).

Past history

K/C/O HTN since 8 years on regular medication of T. Amlodipin 5 mg 1 OD.

Obesity since 12 years.

No history of Diabetes mellitus / Thyroid dysfunction/ Tuberculosis/ Asthma / any surgery.

Personal history

Non-smoker. Occupation: Nurse. Diet: Mixed diet. Daily consumption of excessive sweet and fatty substances. Non- veg: 2 to 3 times/ week. Physical activity: Lack of exercise, sedentary.

Family history:

Father- K/C/O HTN. Mother- K/C/O DM/ HTN

Menstrual history

Attained menopause seven years ago.

Clinical examination

Systemic examination

Investigations

Haemogram, liver function test (LFT), renal function test (RFT) and lipid profile was done on 22/02/2021. Except Serum Triglycerides (770.0 mg/dL), all the other parameters were found to be within normal range.

Diagnosis

Hypertriglyceridemia/ Medoroga

Intervention

The patient was subjected to Virechana karma.

Observations

Patient observed a feeling of lightness in her body, renewed energy and reduced about seven kgs of weight after the completion of Virechana karma. She was advised to repeat her lipid profile after completion of her Samsarjana Krama.

Discussion

Hypertriglyceridemia has been noted in more than 80% of the people who are overweight or obese and causes include some genetic disorders like familial chylomicronemia syndrome, lifestyle factors like alcohol consumption and smoking, high saturated fat intake, excessive sugar intake, decreased physical activity, uncontrolled diabetes mellitus, etc or even some drugs.1

Metabolism of fat

The hydrophobic triglycerides are packed into the core of lipoproteins, to facilitate its transport in the aqueous medium inside the body. Chylomicrons and very lowdensity lipoprotein (VLDL) are the two principal triglyceride rich lipoproteins (TGRL) that are secreted respectively by the intestine and liver. They undergo hydrolysis by the Lipoprotein lipase enzyme releasing free fatty acids and multiple remnant lipoproteins. These remnants are either cleared by the liver or taken up into the vessel wall. The plaques thus deposited further promote vascular inflammation and atherogenesis which leads to cardiovascular diseases especially Atherosclerotic Cardiovascular Diseases.10 A complete or partial blockage in any of the vessel supplying the main organs like the brain or heart can turn into a morbid and often fatal condition in the form of Cerebrovascular accident or cardiac event.

The Jatharagni and Dhatwagni are responsible for converting exogenous food into bodily cells and tissues. Nidanas like Ati Madhura, Ati Snigdha Ahara, Avyayama, Atyasana lead to Jatharagni Dushti and Kaphavriddhi. The Agnimandya and Ama thus generated vitiates the Rasa Dhatwagni and produces Ama Rasa Dhatu. This Ama Rasa Dhatu further causes Medo Dhatwagni Mandya that leads to Ama Roopa Medovriddhi. This is seen as Sthoulya or Medoroga based upon the involvement of Stayi and Astayi Medo Dhatu. The Ama Astayi Medo Dhatu and Kapha Vriddhi are together responsible for Margavarodha Janya Vata Vriddhi.

The Siras are originated from Meda Dhatu and it plays an important role in providing Sneha to these vessels which is important to maintain the elasticity of these vessel walls. According to the above Samprapti, the abnormal Medo Dhatu is circulated throughout the body along with Rasa and Rakta and gets deposited wherever there is Kha Vaigunya and it is termed as Pratichaya. The Vata thus gets vitiated and its Ruksha Guna leads to Shoshana and Kathinya of these Siras or Dhamanis, thereby reducing its elasticity and causing hardening of these vessels. This is called as Dhamani Pratichaya which is considered as a Kaphaja Nanatmaja Vikara by Acharyas. Dhamani Pratichaya or Atherosclerosis causes Strotavarodha in all the Trimarmas leading to Gambhira Vyadhis.

Considering it as Medovaha Sroto Dushti and Medopradoshaj Vikara due to Santarpana, management comprises of Apatarpana. Virechana is one of the Langhana Shodhana having Apatarpana effect indicated in Balawana or Brihat Sharira persons.11 As there is involvement of Kapha and Medas, the Shodhana should be Tikshna.

Probable mode of action

To attain the necessary Niramavastha before starting any Shodhana procedure, Deepana and Pachana was achieved in this patient with Chitrakadi Vati and Agnitundi Vati. Understanding the role of Varunadi Gana as Kapha Medohara, it was chosen for Ghritapana in the present case and it brought about the required Doshotkleshana. Swedana in the form of Bashpasweda helped for Vilayana of the Doshas thus promoting their passage from Shakha to Koshta. Icchabhedi Rasa having Jayapala as its chief ingredient is considered as a Tikshna Virechaka and was chosen as the drug of choice to acquire the required Shuddhi. It helped to eliminate these vitiated Doshas through the Adhomarga. The patient attained 40 Vegas with Kaphanta Shuddhi and Samyak Virikta Lakshanas. Atiyoga Lakshanas were not observed even when the Vega number exceeded 30.

Here the Tikshna Shodhana must have helped to achieve both Jatharagni as well as Dhatwagni Vruddhi after Samyak Strotoshodhana. It must also have aided in eliminating the excess of Kapha and Meda (Ama Asthayi Medo Dhatu) which was reflected in the patient’s fasting Serum Triglyceride level which showed remarkable decrease after the Shodhana. The patient reduced about seven kgs weight after completion of the Virechana Karma. Since the Agni was corrected at the Dhatwagni level, it may be said that the metabolism of fat was also rectified thus addressing the condition of triglyceridemia.

One can question that the result can also be influenced by the restricted diet which was followed during the whole course of treatment. But various studies conducted on the effect of Snehapana concluded that Snehapana leads from slight to significant increase in triglyceride and VLDL levels in the body.12 Therefore in this study, we can rule out the possibility of restricted diet playing a role in the result seen since the patient already had severe hypertriglyceridemia.

It can be concluded that since Ayurveda considers Agnimandya as the root cause for all the ailments, the same holds true in case of hypertriglyceridemia too. Therefore the treatment of the disease should be aimed at correction of the Agni using appropriate use of Shodhana and Shamana methods. The present case is an example where Shodhana in the form of Virechana proved beneficial in lowering the patient’s triglyceride levels.

Conflicts of Interest

None.