Role of Ayurveda and Yoga-Based lifestyle in the COVID-19 Pandemic - A Narrative Review

The COVID-19 pandemic has posed an immense challenge to health care systems around the globe in terms of limited health care facilities and proven medical therapeutics to address the symptoms of the infection. The current health care strategies have primarily focused on either the pathogen on the environmental factors. However, efforts towards strengthening the host immunity are important from public health perspective to prevent the spread of infection and downregulate the potency of the agent. While a vaccine can induce specific immunity in the host, non-specific ways of improving overall host immunity are the need. This scenario has paved the way for the use of traditional Indian therapies such as Ayurveda and Yoga. This review aims at collating available evidence on Ayurveda, Yoga and COVID-19. Further, it draws inferences from recent studies on Yoga and Ayurveda on immunity, respiratory health and mental health respectively to approximate its probable role in prophylaxis and as an add-on management option for the current pandemic.

Tinospora Cordifolia: A review of its immunomodulatory properties

Emergent health threats have heightened human awareness of the need for health and wellness measures that promote resilience to disease. In addition to proper nutrition and exercise, health-conscious consumers are seeking natural-based modalities, e.g. botanical preparations, that positively impact the immune system. In Ayurvedic ethnomedicine, Tinospora cordifolia (T. cordifolia), a deciduous climbing shrub indigenous to India, has been used to historically to combat acute and chronic inflammation as well as to promote a balanced immune response. As a dietary supplement, T. cordifolia has been administered most often as a decoction either alone or in compositions containing other medicinal plant extracts of the Terminalia and Phyllanthus species. Extensive phytochemical characterization of aqueous and alcoholic extracts of different Tinospora species has identified over two hundred different phytochemicals from non-overlapping chemical classes with the most abundant being diterpenoids containing the clerodane-type skeleton. Numerous pharmacology studies have demonstrated that T. cordifolia modulates key signaling pathways related to cell proliferation, inflammation, and immunomodulation. However, rigorous dereplication studies to identify active constituents in various T. cordifolia extracts and their fractions are lacking. In this review, we will summarize the current information regarding T. cordifolia's ethnomedicinal uses, phytochemistry, pharmacological activities, and safety in order to highlight its potential as an immunomodulatory dietary supplement.

Add-on Ayurveda Treatment for Early Stage COVID-19: A Single Center Retrospective Cohort Study From Gujarat, India

The retrospective cohort study aimed to evaluate the clinical outcomes of Ayurveda treatment exposure as an add-on to conventional care in early stage COVID-19 patients admitted at Samaras COVID care center, Ahmedabad, India. Conventional care included Vitamin-c, Azithromycin, and Paracetamol. Ayurveda formulations used as add-on were Dashamula and Pathyadi decoctions along with Trikatu powder, Sanshamani tablet, AYUSH-64 tablet AND Yastimadhu Ghana tablet for oral administration. Considering Add-on Ayurveda medicines as exposure of interest, patients who received Add-on Ayurveda medicines at least for 7 days were included in the exposed group while those who received only conventional care in unexposed group. Data was collected through record review and telephonic interviews. The outcomes of interest were the development of symptoms, duration of symptomatic phase in those progressing to symptomatic stage and mortality. Total 762 participants were included-[541 (71%) in the exposed group and 221 (29%) in the unexposed. Progression to symptomatic phase did not differ significantly between groups [27.6% in exposed, 24.6% in unexposed, adjusted RR 0.85; 95% CI 0.6-1.2]. The total duration of symptomatic phase among those progressing to the symptomatic stage was significantly decreased in the exposed group (x¯ = 3.66 ± 1.55 days in exposed (n = 133); x¯ = 5.34 ± 3.35 days in unexposed (n = 61), p < 0.001). No mortality was observed in either of the groups. Ayurveda Treatment as adjunctive to conventional care reduced the duration of symptomatic phase in early stage COVID-19 as compared to standalone conventional care. Add-on Ayurveda treatment has promising potential for management of early stage COVID-19.

Exploratory studies on the therapeutic effects of Kumarabharana Rasa in the management of chronic tonsillitis among children at a tertiary care hospital of Karnataka

The effect of an Ayurvedic poly-herbo-mineral formulation Kumarabharana Rasa (KR) in the management of chronic tonsillitis (Tundikeri) in children has been assessed in this study. This clinical study was a double-arm study with a pre- and post-test design at the outpatient level in a tertiary Ayurveda hospital attached to a teaching institute located in district headquarters in Southern India. Patients (n = 40) with chronic tonsillitis satisfying diagnostic criteria and aged between 5 and 10 years were selected from the outpatient Department of Kaumarbhritya, SDM College of Ayurveda and Hospital, Hassan. Among them, 20 patients were treated with Kumarabharana rasa (tablet form) at a dose of 500 mg once daily for 30 days (Group A). The other 20 patients were treated with Godhuma Vati (placebo) at a dose of 500 mg once daily for 30 days (Group B). In both groups, Madhu was the Anupana advised. After completion of 30 days of treatment, the patients were assessed on the following day and another investigation took place 15 days later. Statistically significant effects (p < 0.05) in the reduction of all signs and symptoms of chronic tonsillitis after KR treatment were observed. These results indicate that Kumarabharana Rasa has an ameliorative effect in reducing the signs and symptoms of chronic tonsillitis.

Recent Trends in Therapeutic Approaches for Diabetes Management: A Comprehensive Update

Diabetes highlights a growing epidemic imposing serious social economic crisis to the countries around the globe. Despite scientific breakthroughs, better healthcare facilities, and improved literacy rate, the disease continues to burden several sections, especially middle and low income countries. The present trends indicate the rise in premature death, posing a major threat to global development. Scientific and technological advances have witnessed the development of newer generation of drugs like sulphonylureas, biguanides, alpha glucosidase inhibitors, and thiazolidinediones with significant efficacy in reducing hyperglycemia. Recent approaches in drug discovery have contributed to the development of new class of therapeutics like Incretin mimetics, Amylin analogues, GIP analogs, Peroxisome proliferator activated receptors, and dipeptidyl peptidase-4 inhibitor as targets for potential drugs in diabetes treatment. Subsequently, the identification and clinical investigation of bioactive substances from plants have revolutionized the research on drug discovery and lead identification for diabetes management. With a focus on the emerging trends, the review article explores the current statistical prevalence of the disease, discussing the benefits and limitations of the commercially available drugs. Additionally, the critical areas in clinical diabetology are discussed, with respect to prospects of statins, nanotechnology, and stem cell technology as next generation therapeutics and why the herbal formulations are consistently popular choice for diabetes medication and management.

Tinospora cordifolia as a protective and immunomodulatory agent in combination with cisplatin against murine visceral leishmaniasis

Effect of pure herb, Tinospora cordifolia was studied for its hepatoprotective, nephroprotective and immunomodulatory activity against high dose cisplatin treatment in Leishmania donovani infected BALB/c mice. Administration of cisplatin (5mg/kg b.wt. daily for 5 days, i.p.) reduced the parasite load in L. donovani infected BALB/c mice but produced damage in liver and kidney as manifested biochemically by an increase in serum glutamate oxaloacetate transaminase (SGOT), serum glutamate pyruvate transaminase (SGPT), serum urea, serum creatinine and various electrolytes etc. These biochemical analyses were further supported by cisplatin induced morphological changes in kidney, liver and spleen. To combat this pure herb, T. cordifolia (100mg/kg b.wt. for 15 days daily) was used in combination with cisplatin in L. donovani infected BALB/c mice and it was found that all the aforementioned changes were effectively attenuated by T. cordifolia when administered in combination with cisplatin. Moreover, flow cytometric analysis of lymphocyte surface markers of T cells (CD3+, CD4+ and CD8+), NK1.1 and B cells (CD19) indicated prominent enhancement in proliferation and differentiation of lymphocytes. T. cordifolia in combination with cisplatin selectively induced Th1 type of immune response as depicted by enhanced levels of IFN-γ and IL-2 whereas Th2 specific cytokines IL-4 and IL-10 observed a moderate decline. Confirmation of Th1 polarization was further obtained from augmented levels of IgG2a over IgG1 and heightened DTH (delayed type hypersensitivity) response. Thus, our results suggest that treatment by T. cordifolia may be a critical remedy for the amelioration of adverse effects of cisplatin. Thus, this might serve as a novel combination against visceral leishmaniasis in future.

Immunomodulatory and therapeutic potentials of herbal, traditional/indigenous and ethnoveterinary medicines

Herbs/Botanical plants are considered as God's gift to human beings in the form of natural medicines, like the one well known "Sanjeevani booti" described in Hindu Mythology. The traditional and ethno-veterinary practices have been in use for centuries, transferring the knowledge from generation to generation and they are accessible, easy to prepare and administer, with little or no cost at all. Even though the modern developments in therapeutic field brought about a rapid decline in traditional medicine, the plant-based remedies are still having a crucial role as potential source of therapeutic aids in health systems all over the world for both humans and animals. Among the 21,000 medicinal plants listed by the World Health Organization (WHO), 2500 species are native to India, which stands first in the production of medicinal herbs. This innumerable treasure of medicinal herbs brings India the distinction of 'the botanical garden of the world'. Nowadays immune-based therapies are gaining more importance than monovalent approaches which are having limited benefits. Apart from the actions like treating diseases, control of ecto- and endo-parasites, fertility enhancement, bone setting and poor mothering management, an array of herbal medicines have been reported which are having immunomodulatory effects like modulation of cytokine secretion, histamine release, immunoglobulin secretion, class switching, cellular co-receptor expression, lymphocyte expression, phagocytosis and so on. The present article describes in brief few of these important ones viz., ashwagandha, amla, tulsi, arjuna, aloe vera, garlic, turmeric, ginger, shatavari, neem, guduchi, kiwifruit, tut, kamala, palashlata, kokilaksha etc. being used for human and animal health benefits.

Comparable efficacy of standardized Ayurveda formulation and hydroxychloroquine sulfate (HCQS) in the treatment of rheumatoid arthritis (RA): a randomized investigator-blind controlled study

Hydroxychloroquine sulfate (HCQS) is a popular disease-modifying antirheumatic drug (DMARD) despite modest efficacy and toxicity. Ayurveda (ancient India medicinal system) physicians treat rheumatoid arthritis (RA) with allegedly safer herbal formulations. We report a head-to-head comparison in an exploratory drug trial. The objective is to compare standardized Ayurvedic formulations and HCQS in the treatment of RA. One hundred twenty-one patients with active moderately severe RA (ACR 1988 classified) were randomized into a 24-week investigator-blind, parallel efficacy, three-arm (two Ayurvedic and HCQS) multicenter drug trial study; polyherb (Tinospora cordifolia and Zingiber officinale based) and monoherb (Semecarpus anacardium). Study measures included joint counts (pain/tenderness and swelling), pain visual analogue scale, global disease assessments, and health assessment questionnaire. Oral meloxicam (fixed-dosage schedule) was prescribed to all patients during the initial 16 weeks. Patients on prednisolone could continue a fixed stable dose (<7.5 mg daily). Rescue oral use of paracetamol was permitted and monitored. All groups matched well at baseline. An intent-to-treat analysis (ANOVA, significance P < 0.05) did not show significant differences by treatment groups. In the polyherb, monoherb, and HCQS arms, 44%, 36%, and 51%, respectively, showed ACR 20 index improvement. Several efficacy measures improved significantly in the HCQS and polyherb groups with no difference between the groups (corrected P). However, the latter was individually superior to monoherb. Only mild adverse events (gut and skin, and none withdrew) were reported with no differences between the groups. Forty-two patients dropped out. This preliminary drug trial controlled for HCQS demonstrated a standardized Ayurvedic polyherb drug to be effective and safe in controlling active RA. A better-designed study with a longer evaluation period is recommended.

G1-4A, an immunomodulatory polysaccharide from Tinospora cordifolia, modulates macrophage responses and protects mice against lipopolysaccharide induced endotoxic shock

Pro-inflammatory cytokines are known to be the mediators of endotoxic shock and several immunomodulatory herbs can modulate the expression of these cytokines. Therefore we have investigated the possibility of using an arabinogalactan polysaccharide, G1-4A, from the stem of Tinospora cordifolia, for protection against endotoxin induced sepsis. There was 100% protection against lipopolysaccharide (LPS) induced mortality in mice pretreated with G1-4A. To elucidate the mechanism of action, its effect on macrophages, the primary source of these pro-inflammatory molecules was evaluated. G1-4A was shown to bind to the murine macrophages leading to their activation and reciprocally inhibited binding of LPS to macrophages. Following treatment with G1-4A, there was a small increase in serum TNF-alpha and IL-1beta levels. However, challenge with LPS elicited significantly reduced levels of TNF-alpha in G1-4A pretreated mice as compared to the controls while the level of soluble TNFR was enhanced. An increase in serum IL-1beta, IL-6, IFN-gamma levels and decrease in that of IL-10 was observed following challenge with LPS in mice pretreated with G1-4A as compared to the controls. In addition, G1-4A also modulated the release of nitric oxide by murine macrophages. Similar phenomenon was observed in a human monocytic cell line, U937. Thus G1-4A appeared to induce tolerance against endotoxic shock by modulation of cytokines and nitric oxide.

Immunomodulatory and Antitumor Actions of Medicinal PlantTinospora cordifoliaAre Mediated Through Activation of Tumor‐Associated Macrophages

The present investigations were under taken to study whether the tumor-associated macrophages (TAM) of Dalton's lymphoma (DL), a spontaneous transplantable T cell lymphoma, can be activated by the alcoholic extract of medicinal plant Tinospora cordifolia (ALTC). Intraperitoneal administration of ALTC in DL-bearing mice not only augments the basic function of macrophages such as Phagocytosis as well as their antigen presenting ability and secretion of IL-1, TNF and RNI. The results of the present investigation also indicate that the intraperitoneal administration of ALTC slow down the tumor growth and increases the life span of tumor bearing host, thus showing its anti tumor effect through destabilizing the membrane integrity of DL cells directly or indirectly. This is the first study of it's kind regarding the effect of alcoholic extract of Tinospora cordifolia on the activation of tumor associated macrophages and showing the antitumor effect on the spontaneous T-cell lymphoma (DL), thus may have clinical implications.

Evaluation of the antiretroviral activity of a new polyherbal drug (Immu-25) in patients with HIV infection

OBJECTIVE

To evaluate the clinical efficacy and safety of a new polyherbal preparation, Immu-25, in HIV-infected patients.

METHODS

36 patients (10 female, 26 male) with a mean age of 35 +/-10 years, with confirmed HIV infection with a CD4 count <500 cells/microL, received two capsules of the test drug twice daily for 18 months in this open-label pilot study. Patients were evaluated at monthly intervals for general signs and symptoms, development of opportunistic infections, and changes in weight and performance index. Lymphocyte phenotyping and routine haematological, biochemical, hepatic and renal parameters were recorded after every 6 months of drug therapy. Viral load was evaluated before and after every 6 months of treatment.

RESULTS

The polyherbal test preparation produced good symptomatic improvement within 6 months. There was an increase in mean (95% CI) weight from 58 (53-64)kg to 63 (56-69)kg, 64 (58-72)kg and 68 (62-74)kg after 6, 12 and 18 months of treatment, respectively. The incidence and severity of symptoms such as diarrhoea, fatigue, anorexia, cough and fever decreased with drug treatment. There was a decrease in the mean (95% CI) viral load from 326 438 (428 600-186 420) copies/mL to 180 495 (258 300-124 000) copies/mL and 22 069 (42 100-16 000) copies/mL after 6 and 12 months of treatment, respectively. The decrease in viral load was associated with an increase in mean (95% CI) CD4 count from a baseline of 243 (203-388) cells/microL to 336 (263-486) cells/microL after 6 months of therapy, and this continued to rise to 527 (285-767) cells/microL (p < 0.001) and 618 (362-1012) cells/microL (p < 0.001) after 12 and 18 months of treatment, respectively. With the exception of mild gastrointestinal adverse effects, the drug was well tolerated. Both patients and investigators rated the treatment as good or very good.

CONCLUSION

The polyherbal drug Immu-25 showed a favourable effect in patients with HIV infection. The test drug decreased the mean viral load, which was associated with good symptomatic improvement and an increase in the mean CD4 cell count. On the basis of these data, it can be concluded that this herbal drug may have a good immunomodulatory effect and has potential as a co-therapeutic agent in the management of HIV infection. Further studies are warranted to confirm its therapeutic potential.

Ayurvedic medicine. Core concept, therapeutic principles, and current relevance

In the prebiblical Ayurvedic origins, every creation inclusive of a human being is a model of the universe. In this model, the basic matter and the dynamic forces (Dosha) of the nature determine health and disease, and the medicinal value of any substance (plant and mineral). The Ayurvedic practices (chiefly that of diet, life style, and the Panchkarama) aim to maintain the Dosha equilibrium. Despite a holistic approach aimed to cure disease, therapy is customized to the individual's constitution (Prakruti). Numerous Ayurvedic medicines (plant derived in particular) have been tested for their biological (especially immunomodulation) and clinical potential using modern ethnovalidation, and thereby setting an interface with modern medicine. To understand Ayurvedic medicine, it would be necessary to first understand the origin, basic concept and principles of Ayurveda.

Comparative studies of the immunomodulatory activity of Tinospora cordifolia and Tinospora sinensis

The water and ethanol extracts of stems of Tinospora cordifolia and T. sinensis inhibit immunosuppression produced by cyclophosphamide. Ethanol extracts of stems of both the plants inhibit cyclophosphamide-induced anemia. The water extract of T. sinensis is found to be more potent than the other extracts.

Ayurvedic medicine and arthritis

The fundamental principles of Ayurveda are briefly reviewed. The ancient classification of arthritis is described along with the comparisons to the modern system. Though the diagnosis is historical and clinical, it is based on the tridosha hypothesis. The Ayurvedic pathogenesis links arthritis to the gut. Management chiefly consists of diet and lifestyle changes, the panchkarma process, and herbal drugs. The rasayana concept of immunomodulation is introduced. Clinical ethno-validation of the ancient therapy is necessary to meet the modern requirements and set up an interface with modern medicine.

An immunologically active arabinogalactan from Tinospora cordifolia

An arabinogalactan of mean M(r) 2.2 x 10(6) has been isolated from the dried stems of Tinospora cordifolia and examined by methylation analysis, partial hydrolysis and carboxyl reduction. Purified polysaccharide showed polyclonal mitogenic activity against B-cells, their proliferation did not require macrophages.

Immunomodulatory effect of IM-133

The immunomodulatory effect of IM-133, a polyherbal formulation, has been investigated. Treatment with IM-133 enhanced the delayed type hypersensitivity (DTH) response in mice. IM-133 enhanced the in vitro response of splenocytes to mitogenic challenge. The in vivo treatment also stimulated the ex vivo lymphocyte proliferation, while the humoral response to sheep RBCs (SRBCs) was unaffected. The preferential stimulation of the components of cell mediated immunity (CMI) indicate that treatment with IM-133 affords non-specific immune stimulation.

Adaptogenic properties of six rasayana herbs used in Ayurvedic medicine

Plants from all over the world such as Eleutherococcus senticosus, Panax ginseng, Raponticum carthamoides, Rhodiola rosea, Withania somnifera and Ocimum sanctum have been extensively evaluated for their adaptogenic potential. However, none of them has been successfully introduced as an adaptogen in the clinic. This paper discusses some of the problems in evaluation of adaptogens which have precluded their inclusion as clinically useful drugs. We further discuss our results with six rasayana plants from Ayurveda, which were studied for their adaptogenic potential. The whole, aqueous, standardized extracts of selected plants (Tinospora cordifolia, Asparagus racemosus, Emblica officinalis, Withania somnifera, Piper longum and Terminalia chebula) were administered orally to experimental animals, in a dose extrapolated from the human dose, following which they were exposed to a variety of biological, physical and chemical stressors. These plants were found to offer protection against these stressors, as judged by using markers of stress responses and objective parameters for stress manifestations. Using a model of cisplatin induced alterations in gastrointestinal motility, the ability of these plants to exert a normalizing effect, irrespective of direction of pathological change was tested. All the plants reversed the effects of cisplatin on gastric emptying, while Tinospora cordifolia and Asparagus racemosus also normalized cisplatin induced intestinal hypermotility. Tinospora cordifolia was also tested for its ability to modulate the changes occurring in the phagocytic activity of peritoneal macrophages after exposure of rats to either carbon tetrachloride or horse serum. It was found to normalize the phagocytic function irrespective to the direction of change, complying to the definition of an adaptogen. All the plant drugs were found to be safe in both acute and subacute toxicity studies. Studies on the mechanisms of action of the plants revealed that they all produced immunostimulation. The protection offered by Tinospora cordifolia against stress induced gastric mucosal damage was lost if macrophage activity was blocked. Emblica officinalis strengthened the defence mechanisms against free radical damage induced during stress. The effect of Emblica officinalis appeared to depend on the ability of target tissues to synthesize prostaglandins. Recent data obtained with Tinospora cordifolia suggest that it may induce genotypic adaptation, further opening the arena for more research and experimentation.

Immunoprotective effect of IM-133

We studied the immunoprotective effect of IM-133, a poly-herbal formulation, against E. coli-induced intra-abdominal sepsis. Treatment with IM-133 afforded protection against the septic shock induced mortality. The in vivo treatment has enhanced nitric oxide production and phagocytic ability against C. albicans by peritoneal macrophages in Balb/c mice. The protective effect of IM-133 appears to be by virtue of its immunomodulatory activity and finds application in the clearance of intra-cellular pathogens.

Evaluation of the antineoplastic activity of guduchi (Tinospora cordifolia) in cultured HeLa cells

Exposure of HeLa cells to 0, 5, 10, 25, 50 and 100 microg/ml of guduchi extracts (methanol, aqueous and methylene chloride) resulted in a dose-dependent but significant increase in cell killing, when compared to non-drug-treated controls. The effects of methanol and aqueous extracts were almost identical. However, methylene chloride extract enhanced the cell killing effect by 2.8- and 6.8-fold when compared either to methanol or aqueous extract at 50 and 100 microg/ml, respectively. Conversely, the frequency of micronuclei increased in a concentration-dependent manner in guduchi-treated groups and this increase in the frequency of micronuclei was significantly higher than the non-drug-treated control cultures and also with respect to 5 microg/ml guduchi extract-treated cultures, at the rest of the concentrations evaluated. Furthermore, the micronuclei formation was higher in the methylene chloride extract-treated group than in the other two groups. The dose response relationship for all three extracts evaluated was linear quadratic. The effect of guduchi extracts was comparable or better than doxorubicin treatment. The micronuclei induction was correlated with the surviving fraction of cells and the correlation between cell survival and micronuclei induction was found to be linear quadratic. Our results demonstrate that guduchi killed the cells very effectively in vitro and deserves attention as an antineoplastic agent.

Cordifolisides A, B, C: norditerpene furan glycosides from Tinospora cordifolia

Several glycosides were isolated, as polyacetates, from the n-BuOH fraction of the Tinospora cordifolia stems. The structures of three new norditerpene furan glycosides cordifoliside A, B and C have been established by 1D and 2D NMR spectroscopy.