R. Compound
in Rheumatoid Arthritis
by
Dr. K. RAMACHANDRA, MD.,
Professor of Medicine, Madras Medical College & Physician, Govt. General Hospital, Madras
P.Gin MD ., Madras Medical College, Madras
INTRODUCTION:
Rheumatoid Arthritis
today is highly prevalent and commonly met with disease in the sophisticated
society of the modern age. Its aetiology still being the subject of doubt and
speculation, which has given rise to many controversial conjectures, and the unsolved
mysteries of this disease has christened it as an incurable condition, liable
to remissions and exacerbations, lasting for variable periods. Spontaneous
permanent remission of this disease has been noted often and the
search for a drug which
may induce such a remission is being sought with futile results. Very many
drugs belonging to the analgesic group have
been tried in this
disease with encouraging results but unfortunately recurrences after withdrawal
are so common that
it cannot be a specific
in the management of
this condition. Steroids have also been
used extensively
with favorable
control of pain, swelling
and constitutional
symptoms but permanent
disappearance of this disease has not been noted.
On the other hand, withdrawal has been
associated with severe
recrudescence that these drugs
have to be given in
a maintenance dosage for long
periods. This long term management of Rheumatoid Arthritis
with steroids is fraught
with many side reactions
solely concerned with its
antianabolic effect
that the bones in
Rheumatoid Arthritis which are already theseat of
porosis is enhanced with lytic changes. There are many more drugs which have
been used' empirically in the treatment of this disease which have not stood
the test of time and have been abandoned.
NATURE OF DISEASE:
The disease is classified
under the collagen disorders and appears to have an immunological basis, the
exact agent which excites this immune reaction has not been clearly elucidated.
Many drugs, especially antibiotics may have a role to play in induction of
immune reactions which localizes itself in connective tissues of the body
especially the synovium in rheumatoid arthritis. This immuno-synovia arthritis
continues to progress, till the immune bodies are antagonized
or neutralized or their production annulled with suitable, therapeutic agents.
In the same manner infections acute or chronic in a wide spectrum of diseases,
may excite an immunological reaction which may culminate in the development of
rheumatoid arthritis. Septic foci lurking in various organs in the body may be
a contributing factor in the development of this syndrome. Food
hypersensitization may also be incriminated in the development of synovial
inflammation. It is not possible to decide aboutthe nature of the allergen,
responsible for thiswide spread connective, tissue disorder going under various
names forming any integral partof different syndromes under connective tissue
disorders.
This hyper-sensitization phenomenon whose mode of
onset, progress and behavior being variable, may be associated with the level
of antibodies and concentration of the antibodies in the connective tissue;
spontaneous remission being associated with the lowering of antibody
concentration at the synovial site before permanent destructive changes have
occurred in these tissues Long continued fixation of these antibodies usually
causes permanent changes in the synovium and connective tissues of body that
irreversible changes are an outcome.
R. Compound was tried in rheumatoid arthritis with the
aim of reversing the changes in the synovium and favorable results have been
noted by clinical assessment of nearly 60 cases treated in Govt. General
Hospital It is encouraging to note that R. Compound is non-toxic without any
deleterious effect on bone marrow or other vital organs of the body.
WHAT IS R. COMPOUND:
R. Compound is an indigenous druq manufactured by
Messrs, Alarsin Pharmaceuticals containing the following ingredients: y
Mahayograj Guggul with
gold bhasma 200 mgms
MaharasnadiQuath
67 mgms
Guggul: English-lndian , Bedellium–Salaitree - Gum
Guggul, Tamil-Gukkulu; Maisatchikunjiliyam. Telugu - MaisakshiGuggulu
It is an Oleo Resin containing volatile oil gum-resin
and a bitter principle.
It is a demulscent. aperient, carminative,
antispasmodic and is used in rheumatism nervous disorders, scrofulous
affections' urinary and skin diseases.
It is excreted through skin, mucous membranes and
kidney and probably throuqh synovium and during the course of its excretion,
exerts an anti-inflammatory action it has also anti-supportive properties and
can be taken for a long time.
Gold in an ash form has also mild anti-inflammatory
properties.
Maharasnadiquath is prepared bv processing twenty five
different herbal drugs Its chief ingredient is "Rasna" English-Alpineachinensis.
Tamil—Chittrattai. Telugu—SannaRashtram.
Rasna has anti-rheumatic, analgesic, anti-inflammatory
and anti-pyretic actions. It is excreted through skin and kidneys having
diaphoretic and diuretic and detoxicating properties. It may also be excreted
through thesynoviamembrane.
R. compound was subjected to trial in cases of
rheumatoid arthritis in the Rheumatic Care Centreof Govt. General Hospital and
the effects of this drug on patients were noted from various angles.
Subjective, Objective, Radiological and Biochemical changes were recorded.
R. Compound like other drugs has anti-inflammatory
properties and like other remedies is used in the management of Arthritic
disorders characterized by pain. Analgesics have a local effect on hyaluronic
acid metabolism and claims that its action is mediated through the pituitary
adrenal axis is also in vogue. The analgesics like Aspirin Phenylbutazone,
Indomethacin have a very potent effect in relieving non-infective inflammatory
processes but not long lasting, as withdrawal of the agent is associated with
recrudescence.
Gold which is a constituent of R.Compound is a drug which has been reputed for
its anti-inflammatory properties from time immemorial. Its use in Tuberculosis
is well documented but discontinued due to the specific antibiotics and
chemotherapeutic agents which, have been introduced. Moreover, Gold is highly
toxic and fraught with dangers of severe reactions. Many heavy metals has such
properties. Arsenic, Mercury, Bismuth were all drugs extensively used in the
past but have been temporarily discontinued at present having been replaced by
potent and specific chemotherapeutic agents. Its revival may be expected as
these drugs can still be relied upon for the management of chronic
inflammations.
The role of heavy metals in
inflammation has not been thoroughly understood. There is a competition for the
sulphydryl groups and the metals gets fixed to the tissues in conc, which makes
it exert its lethal effect on organisms. It also helps in clearing away the cellular
and exudative reactions in nonspecific inflammatory processes. These heavy
metals havebeenused extensively before antibiotics and in Indian medicine still
continue to be used.
In Ayurveda, which is the
ancient system ofIndian Medicine heavy metals are made less toxic by reducing
them into an "ash form" by special process. This ash is known as 'Bhasma'
and can be used for prolonged periods without anticipating any side reactions,
which are usually associated with the use of salts of heavy metals. It is
therefore claimed by the Ayurvedic workers, that 'Gold-Ash' is devoid of the
toxic effects of 'Gold-Salts' and is recommended in the long-term therapy of
diseases.
It may not be incorrect to
postulate that these drugs prevent the destructive effects of antibodies on the
tissues or may act as immunosuppressive agents preventing the formation of
antibodies in large quantities in the. lymphatic tissues of the body.
Whatever may be its mode of
action, gold continues to be used in the management of Rheumatoid Arthritis- R.
Compound has Gold-Bhasma in small quantities, which makes it safe for long,
term therapy of this disease. The reactions met with are almost negligible and
the drug has been noted to be very beneficial in this disease.
R. Compound was used in 60
cases of Rheumatoid Arthritis both in the inpatient and outpatient departments
of Govt. General Hospital for variable periods. The cases on whom R. Compound
was used were selected at random, with no uniformity of clinical features, the
patients subjected to trial were in different stages of this disease process, Some
of them had deformities and wasting of muscles, and others had pain with
negligible swelling. A wide spectrum in the. evolution of this disease was
selected for treatment with R. Compound.
The Age Incidence of the
cases selected is as follows:
0-10
: NIL
11-20 : 6 41-50 : 16
21-30 : 13 51-60 : 5
31-40 : 19 61-70 : 1
Sex Incidence: Females – 36 Males – 24
Grading of Cases:
1. Stiffness in joints
2. Pain in small joints
3. Pain and swelling of one or several joints.
4. Pain and wasting of muscles
5. Deformities of joints due to contractures.
Cases were grouped into various (A.R.A) Grades:
Classical – 19 Definite – 30 Probable – 11
R. Compound was used as a
routine in small dosage schedule of two tablets thrice a day. Where the disease
was resistant, the dosage was raised to 3—4 tablets thrice aday.
Patients tolerated the drug
well and toxic reactions of a severe type was not noted in any patient. Mild
gastric disturbances were the only symptoms which occurred and were tolerated
well.
The beneficial effects of R
Compound were noted within 7 days after commencement of therapy and theearliest improvement noted was mainly
subjective There was relief of stiffness and improve in general health, like
return of appetite and feeling of wellbeing. This itself infused certain amount
of confidence in the patients who experienced a sense of psychologicalrelief.
Pain, gradually disappeared
within 12-14 days after starting the drug as shown below:
Symtoms |
1st
week |
2nd
week |
3rd
week |
4th
week |
No
Improvement |
|
Relief of
Stiffness |
29(48%) |
19 (32%) |
4 (7%) |
- |
8 (13%) |
|
Relief of Pain
in Joints |
17 (29%) |
30 (50%) |
3 (5%) |
2 (3%) |
8 (13%) |
Swelling of the joints subsided gradually in the
majority of patients but in a few, there was quick relief. Patients who had an
acute form of the disease responded earlier than those who had been suffering
for long periods or who were subjects of recurrences. In an average case
swelling subsided within a period of 1-3 months. Patients have been followed up
for nearly 6-9 months and recurrences have not been noted.
R Compound was given in a small dosage to startwith
(two tablets thrice a day) but increased to 3 tablets thrice a day if
improvement was not noted on the 5th day after initiation of therapy. In some
of the patients, a higher dosage pattern was instituted, 3-4 tablets thrice a
day.The dosage of the drug was reduced when swelling or pain disappeared and
maintenance dosage of one tablet thrice
a daywas given continuously without stopping drug.
R. Compound relieved stiffness, pain and swelling of joints but had no effect
on the deformities and on other long standing changes associated with the
disease viz, wasting of muscles, contractures etc. Osteoporotic changes
persisted even after relief of pain in long standing cases.
Individuals on R. Compound in this series increased in weight and had feeling
of well being and were able to move about more comfortably. There was
improvement in their behavior and were able to take part in social activities.
RESISTANT CASES:
In this series of 60 cases, eight of them showed mild or no response at all. These were analyzed retrospectively to explain the failure of improvement and the following conclusions were made,
1.
All the cases were severelyanaemic andresponse to blood transfusions and haematinics were poor. It was not possible to improve the anaemia beyond a certain degree. s
2.
Three of the cases had kidney disorders which were silent and noted on investigation.A routine I V. Pyelogram showed changes suggestive of pyelonephritis.
3.
Three cases had gross deformities in the hands, feet, elbow and in other joints.
4.
Many of the patients had been suffering from the disease for several years ranging from 2-5 year with frequent recurrences associated with gross constitutional disturbances viz,loss of appetite, weight and lack of confidence.
5.
Radiologically marked osteoporotic changes were noted in the bones of the affected joints and wasting of muscles.
6.
All the patients had positive Rose Waaler Test.
7.
On analysis of serum proteins in the blood, the following observations were made in the cases resistant to treatment.
Group l-cases which responded. Group II -cases resistant.
(ii)
(i) The total protein level in
patients resistant to treatment were lower than the group which responded and
did not show any rise after administration of R. Compound as estimated after a
period of one month.
(ii) The Albumin level in the blood was almost the same as the group l, and did
not rise appreciably after R. Compound, whereas in Group II, there was an
elevation after treatment.
(iii)Total Globulin level in the blood showed a rise in level in Group II,
whereas in Group I, there was a fall indicating its failure as an
immunosuppressive agent in the group.
(iv) All the Globulin Factions Alpha1, Alpha2,Beta, Gamma
showed no change after administration of R. Compound in Group II, whereas in
Group I, there was a uniform fall in these levels.
(v) Alpha1, Alpha2 fractions of Globulin in the resistant
cases (Group II) were lower than in Group I.
(vi) There was also an appreciable fall in the ESR in the cases which responded
to R. Compound, whereas the fall in the other group was not significant.
The above changes in the level of serum Proteins and the fractions in the
Globulin which were estimated are of prognostic significance giving an
indication about the efficacy of R. Compound indirectly. Such cases which did
not respond may have some other underlying diseases or biochemical changes
preventing the action of this drug on the synovium, which has to be studied in
more detail.
R. Compound has been found to be uniformly effective
in relieving the main features of Rheumatoid Arthritis in the majority of cases
inducing remission for periods which patients had not experienced before. The
drug can be continued for prolonged periods in a maintenance dosage without the
occurrence of toxic effects.
The drug has been subjected to trial in the Rheumatic
Care Centre at Govt. General Hospital to study its efficacy and validity of the
claims put forward by other authors about its encouraging therapeutic effects.
The drug was supplied by Messrs. Alarsin Pharmaceuticals, Bombay, and its
composition is purely indigenous. In a disease like Rheumatoid Arthritis, where
no useful and specific remedy is available, R. Compound
has in the trial conducted proved to be an efficacious and reliable drug. We
are thankful to Mr, K.M.S. Chetty for having placed at our disposal R. Compound
for trial.