A case of non-alcoholic steatohepatitis solved by unani formulations (Qurs-e-Zarishk, Arq mako and Arq Kasni)

INTRODUCTION

Non-alcoholic steatohepatitis is defined as the fat buildup of greater than 5 percent together with the histologic indications of necro-inflammation and hepatocyte ballooning and degeneration.¹ Non-alcoholic steatohepatitis can be either primary or secondary. Primary NASH also known as typical NASH is associated with central obesity and often type-2 diabetes mellitus, but without a specific additional cause. Secondary NASH is associated with a specific, non-alcohol-related problem, drug or toxin induced causes.² In Unani System of medicine, based on the signs and symptoms of NASH, it can be studied under the concepts of warm-e-kabid balghami (phlegmatic hepatitis) and su-i-mizaj kabid barid (altered cold temperament of liver).In Sū-i-mizaj kabid barid the mizaj of liver is changed from hot and moist to the barid due to the eratic food habits and consumption of fatty foods.This condition causes the impairment of quwwati jadhiba and quwwati hadima leading to the signs and symptoms of the disease.³ Also the disease can be related to the waram-al-kabid balghami which is an inflammatory condition that affects the liver, potentially leading to the swelling of liver tissue, if this condition is left untreated it transforms into the complicated form which can be correlated to NASH.⁴

CASE REPORT

A diagnosed case of NASH was taken for the study from OPD, department of Moalajat, Regional Research Institute of Unani Medicine, Habak, Srinagar, Kashmir 190006.The case was a 60-year-old female patient, diabetic, hypertensive and euthyroidic who came to the OPD of RRIUM Srinagar, with pain in her right hypochondrium, which was gradual in onset, dull in character, mild to moderate in severity, non-radiating and associated with fatigue. The patient was already a diagnosed case of NASH, when she approached in OPD, for alternative options of treatment. She was a known case of type-2 diabetes for the past 18 years, was on oral hypoglycemic drugs for last 17 years and she was started on insulin from one year. In addition to this, patient was also a known case of hypertension, was put on ARB’s (Telmisartan 40 mg) from last 10 years. She had also undergone cholecystectomy 5 years back, tubectomy 30 years back. Family history for NASH was non-significant, patient had no history of alcohol consumption or smoking. She was in her menopause with obstetrical history as G3P3A0. Her appetite was significantly reduced, sleep and bowl were normal.

On General Examination, she was obese with a weight of 85 kg and height 5 feet with BMI 36.6 kg/m2. All the vitals were normal (BP= 130\80 mmHg, pulse=74 bpm, respiratory rate=16/min and temp=98f). No lymphadenopathy, cyanosis, edema, jaundice or anemia could be seen. On systemic examination, patient was alert, conscious and well oriented with time, person and place. S1, S2 clearly heard, respiratory sounds were normal. On evaluation of Gastrointestinal system, right hypochondrium was slightly swollen and tender and she had mild abdominal distension.

Duration of study

The duration of study was 3 months. Total of six follow ups were done, each after the duration 15 days.

Consent

The patient was willing to be the part of our study and informed consent was taken prior to the start of intervention.

Intervention

Life style modification

Following lifestyle modifications were advised to the patient. The patient was strictly advised to avoid sedentary life style. Light to moderate type of exercises which were explained to the patient were included in the daily routine. A brisk walk of 10 min daily was also advised to the patient.

Dietary changes

Following dietary changes were practiced. Reducing the number of calories in the diet through the practice of portion control. Eating healthy diet that was rich in fruits and vegetables, whole grains and low in saturated fats. Patient was advised to limit animal-based foods like red meat. Patient was also suggested to limit the amount of salt and sugar in her diet. Use of limited quantity of oils for meal preparation was also advised.

Drugs

Qurs-e- zarishk, mentioned in one of the renowned Unani texts, consisting of following ingredients was given in the dose of 500 mg two times a day after lunch and dinner along with water.⁵ Arq mako and Arq kasni with ingredients mentioned in Table 2, were also given in the dose of 20 ml each along with Qurs-e-Zarishk at the same time.⁵

Assessment

The patient was assessed with the help of Fibroscan before and after the study and various Scales such as Hunger Scale, Fatigue Assessment Scale and Visual Analog Scale, were used to assess the signs and symptoms of the disease fortnightly i.e., on every follow up.

A significant change can be seen in the fibro scan before and after the intervention, which is clearly evident from the below reports of fibro scan.

Also, improvements in the signs and symptoms of disease have been seen like improvement in appetite, fatigue and pain which was evaluated with the help of following scales.

In addition to this, the medications given to the patient proved to be helpful in reducing the weight which is considered as an important step in the management of NASH. Weight of the patient was reduced from 85 kg at baseline to 77 kg in the 6th follow-up. Further post follow ups were done after every two weeks and patient was advised not to discontinue the medication.

DISCUSSION

As stated above, In Unani System of medicine NASH is studied under the concept of warm -e-kabid balghami and su-i-mizaj barid. The intervention that has been given to the patient correct the causes i.e warm-e-kabid and su-i-mizaj barid which if left untreated can transform into the NASH. In our case study there was a significant change in the fibroscan reports of the patient along with the improvement in signs and symptoms of disease.

Such improvements can be attributed to the pharmacological actions of the drugs used, such as muhallil-i-Awram (anti-inflammatory), mulattif (demulsant), muqaw-e-Kabid (liver tonic) and mudir-e-baul (diuretic) 5.As the root cause of this disease lies in the inflammation and derangement of mizaj of the liver and such actions of the drugs address these causes which ultimately helps in treating the disease, preventing the further progression and helping in the better prognosis of disease. In addition to this, the main ingredient of Qurs-e-Zarishk is berberis aristata which contains berberine (an isoquinoline alkaloid) as its principle constituent, due to its pharmacological activities like anti-oxidant6 and anti-inflammatory (reduces the levels of hs-CRP, IL-6 and TNF-α), this reduction in anti-inflammatory factors particularly hs-CRP helps in the decrease of insulin resistance, triglycerides and total cholesterol.⁷

Thus, forming an important constituent in the treatment of metabolic syndrome, which is considered as one of the main etiological factors of Nash.⁸ Also the other medications given to the patient were Arq-e-Mako and Arq-e-Kasni. Arq-e- Kasni with Cichorium intybus as its main ingredient possesses the biological activities like hepatoprotective, anti-inflammatory, antioxidant, hypolipidemic and anti-diabetic and Arq-e-Mako contains Solanum nigrum as main ingredient with solanine being a prominent constituent possesses antidiabetic and anti-inflammatory action.^9,10 Therefore, Qurs-e-zarishk along with Arq-e-Mako and Arq-e-Kasni possesses the wonderful activities that cure the cause of NASH.

CONCLUSION

From the above-mentioned results and discussion, we can conclude that Unani system of medicine along with a modified life style and restricted diet plan plays a vital role in the management of chronic illness by addressing the root cause of disease and one such disease is the non-alcoholic steatohepatitis. Hence Unani system of medicine can also be used as option for the treatment of NASH and also to prevent its further progression and improve the prognosis. However, more advanced studies with robust methodology needs to be carried out.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

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