Introduction
COVID-19 is an infectious disease caused by the newly discovered coronavirus. COVID-19 is caused by severe acute respiratory syndrome coronavirus 2 (SARS-COV2). It is a high-enveloped single-strand RNA virus that is found in humans and animals, it belongs to the Coronaviridae family. This paper is intended to review and elaborate the ayurvedic rejuvenating formulations i.e ‘Rasayana’ for managing the post COVID challenges in patients. In Ayurveda, in the ancient text Sushrut Samhita there is mention of aupasargik disorders which spread by contact of patients’ used cloths, ornaments, bedding etc. Contagious diseases are hence described by Sushruta.1
COVID-19 outbreak all over world
On 31st December 2019 WHO was informed about patients with pneumonia with unknown cause in Hubei Wuhan City, China. Novel corona virus was identified as a cause, by Chinese authorities on 7th January 2020 and named “n-COV”. Meanwhile, 2019 n-cov was renamed “SARS-COV2” by the international committee on taxonomy of viruses. WHO has declares this a global health emergency at the end of January 2020. First case of COVID-19 in India were reported on 30 January 2020, after September 2020 high peak period noted and cases declined at the end of October 2020. It took a more than one year to outright 1st wave of infection. Since the middle of March 2021, the 2nd wave has started and on April 09 2021 highest cases has been recorded in India.2 3rd wave of Omicron has started at 3rd week of November 2021in India.
Till the date 014 June 2021, 528,816,317confirmed cases and 6,294,969 deaths recorded globally. In India there have been 43,236,695 cases with 524, 777 deaths reported to India.3 A list of variants of concern as per WHO mentioned4 in Table 1.
Table 1
Variants of concern as per WHO
Post COVID
In the guideline, two definitions of post-acute COVID-19 are given :1) Ongoing symptomatic COVID-19 for people who still have symptoms between 4 to 12 weeks after start of acute symptoms; and 2) Post COVID syndrome for people who still have symptoms for more than 12 weeks after the start of acute symptoms This may last up to 1 year5, 6 Only 10.8 % of patients had no manifestation, once recovered from the disease. The most common symptom reported was fatigue, seen in almost 72.8 % followed by anxiety in 38%, joint pain in 31.4%, and continuous headache in 28.9% cases. Also, critical manifestations like diabetes mellitus, pulmonary fibrosis, stroke, renal failure, etc. were reported by the subjects.7 The common symptoms recorded in the post COVID ailments are shown in Figure 1.
Adverse effects of modern medications
In the treatment of acute COVID-19, several drugs are used such as chloroquine, hydroxychloroquin (HCQ), favipiravir, ivermectin, azithromycin, remdisivir, methylprednisolone, tocilizumab, etc. Chloroquine has shown psychiatric side effects like stress insomnia, visual hallucination, anxiety and GIT problem in COVID-19 patients.8 It is also reported that some serious issues regarding use of HCQ such as muscle weakness, diplopia, seizures, insomnia, irritability, depression, anxiety have been reported. Azithromycin and Dexamethasone were widely used in acute COVID-19 cases having antibiotic and anti-inflammatory action respectively but were not significant. Most common side effects of azithromycin and dexamethasone are gastritis, vomiting, headache recorded. Remdisivir also reported severe side effects such as organ failure, GIT upset, increased level of liver enzymes.9 Tocilizumab is immunosuppressive humanized monoclonal antibody drug has significantly inhibiting IL6 enzyme but many side effects were recorded such as respiratory failure, GIT upset, headache, hypertension, reactivation of herpes zoster.
Vaccination do not provide full (100%) protection. Oxford AstraZeneca vaccine shows Up to 72% efficacy with who received 2 standard dose with varying 4 to 12 weeks interval.10 Bharat Biotech BBV152 COVAXIN shows efficacy with specific post dose 2, only 65 % against Delta variant. Till the date No data available for efficacy of vaccination against Omicron variant & XE Variant.11
COVID is infectious disease mainly affect respiratory disorder, circulatory system. In COVID patients, Agnimandya (weakened digestive power) as a residual symptoms of post COVID which leads to dhatukshya avastha. Dhatukshaya can be treated by administrating Rasayan drugs (immunobooster) and it is also deals with enhancing immunity or rejuvenating body tissues. Hence it is possible to prevent further complications. Hence Rasayan chikitsa may be useful in post COVID management of patients. Ministry of AYUSH has also recommended chyawanprash as rasayan (immunomodulatory medicine) in post COVID management.12
Rasayan Concept in Ayurveda
The drugs which are rejuvenators and lead to longevity in humans are known as Rasayan. Drugs which ward off old age and diseases are called Rasayan (Rejuvenators).13 There are 2 types of Rasayan on the basis of therapy i.e Kutipraveshik Rasayan (indoor specialized therapy) and Vatatpika Rasayan (outdoor therapy) described in Charak Samhita. Kutipraveshik Rasayan includes strict rules and restrictions regarding diet and lifestyle. Vatatapika is includes OPD based prescription and patient can continue their normal lifestyle. There are no strict restrictions on daily diet and activity. For instance, the well-known formula Chyawanprash can be administered by both ways, as indoor and outdoor therapy. A recent study on chyawanprash shows potential prophylactic agent against infection of SARS-COV2.14 Ministry of AYUSH, Government of India also recommended chyawanprash for prophylactic care as well as post COVID management.12 Outdoor therapy of rasayan is more convenient a nowadays, which does not include stay in kuti [special room] and does not require strict diet, a drug dose is less, convenient. Among two Kutipraveshika Rasayan is superior to Kutipraveshika Rasayan However, now a days Vatatpika Rasayan are commonly used. The benefits of rasayan therapy ( rejuvenating) are shown in Figure 215
In Ayurveda classic texts, number of drugs (herbs/medicine) mentioned known for Rasayan drugs (Immunomodulatory) activity as well as its efficacy in multiple disorders. Rasayan drugs mentioned in different pharmaceutical forms including herbal powder, fresh herbs juice, medicated milk, medicated ghee, semisolid formulations. In Charak Samhita, prophet Charak mentioned a specialized category under medhya rasayan (formulations to improve memory & intellect) i.e juice of Centella asiatica, Glycyrrhiza glabra, Tinospora cordifolia and Convolvulus pluricaulis.
Following are some of the common symptoms of post COVID patients, which need to be treated. Ayurvedic Rasayan drugs can be promising for such treatment. Many Ayurvedic physicians are prescribing some of these rasayan formulations for preventing and treating COVID-19 related symptoms.
Post COVID Health Challenges in Patients
Fatigue
The most common symptom reported in post COVID. Post COVID fatigue is defined as decrease in the physical and /or mental performance that result from changes in central, psychological and/or peripheral factor due to COVID-19 disease.16
Central nervous system related factors
Central factors influencing post COVID fatigue may be result of virus invading CNS. Following phenomenon may be responsible for fatigue.17 dopamine, serotonin which is important for pleasure, motivation and action.B) Intrinsic neuronal inflammationC) Demyelination
Psychological factors
Quarantine protocol, social distancing, isolation have proven effective role in slowing spread of virus, but further which result in stress, anger, anxiety, depression. Due to alteration the levels of neurotransmitter like dopamine and serotonin. Rasayan containing Tinospora cordifolia, Centella asiatica, Glycyrrhiza glabra, Convolvulus pluricaulis, gold are used for reducing stress, anxiety.
Peripheral factors
Post COVID fatigue may also occur from several peripheral factors. COVID-19 have ability to infect multiple tissue types, with special potential to target skeletal muscles and therefore contribute to fatigue.18 In active COVID-19 lungs activates various leucocytes to cascade of cytokine, like interleukin.6 Elevation of IL6 may disturb muscle haemostasis and muscle loss which result into fatigue. In recent studies shows dysregulation of immune system due to COVID-19 which specifically act on lymphocytes, T lymphocytes, neutrophil-lymphocyte ratio.19
Ayurveda, fatigue can be correlated with the shrama which is the symptom of Rasavaha srotas disturbance. This is most common symptom after COVID infection. Due to weakened digestive power (agnimandya) there is generalised anorexia in active COVID-19. This can be treated with the help of Rasayan chikitsa like Bramha Rasayan, Chywanprash, Amalak Rasayan, Nagbala Rasayan, Haritakyadi Rasayan, Vidangadi Rasayan, Haritakyadi yoga, ippali Rasayan, Vardhman Pippali Rasayan in general, the Rasayan which contain Phyllanthus emblica and Terminalia chebula are known for rendering longevity and rejuvenation of full body. In Ayurveda, Amalaki is a fruit known as the best drug for immune modulatory action, leading to prevention of aging.
Headache
Headache is frequent symptom of ongoing SARS-COV2 infection however headache continuous even after recovery. It can spread throughout skull, giving a feeling of constriction and weight at the top of head. If the infection affects a subject who already suffering from migraine, it multiplies the crises. The exact pathophysiology is unknown but some studies believe that pain may be due to the cytokine storm.20 No medications have shown beneficial effective till date. Rasayan containing Withania somnifera, Sida cordifolia, Shatavari (Asparagus racemosus), Chyawanprasha are useful for treating headache.
Weight loss
Weight loss is defined as 5% reduction of body weight from initial weight. Earlier study found that weight loss and malnutrition were highly prevalent in COVID-19 survivors. Nearly 30% patient lost 5% of baseline body weight and half were at risk of malnutrition. COVID-19 is significantly associated with unintentional weight loss and malnutrition have been recently reported over three month follow up after discharged.21 Several mechanisms may contribute to weight loss and malnutrition like alteration of smell, taste, lack of appetite could affect food intake, fatigue, chronic polymorbities, prolong ICU or hospital stay, older age, assisted ventilation. Patients with severe hyper inflammation (peak CRP values), impaired renal Function (GFR less than 60ml/min/1.73m2) and cytokine storm may affect the nutrition.22 In active COVID-19 lungs activates various leucocytes to cascade of cytokine, like interleukin.6 Elevation of IL6 may disturb muscle haemostasis and muscle loss which leads to significant weight loss.18
Weight loss might be due the multiple etiology, such that hampered digestion power, effect of severe viral infection leading to wasting of body, as well as due the various drugs used in acute COVID-19 and impaired multiple functions. For treating weight loss, the rasayan containing gold bhasma, Asparagus racemosus, Withania somnifera, Sida cordifolia, Chyawanprash are useful. Cow ghee (clarified butter) is a part of many rasayan drugs, which helps in treating weight loss.
Anorexia after COVID infection
One of the most commonly seen symptoms in acute COVID-19 as well as post COVID. COVID-19 has potential to alteration in gut micro biome (gut dysbiosis) even after the clearance of SARS-COV2.23 In recent study found that microbiota was not restored to normal levels after 6 months of acute COVID-19 infection.24 Anorexia is also side effect of drugs viz. chloroquinine, hydrochloroquinine, azithromycin, dexamethasone, remdisivir, tocilizumab which were used in treating infected patients of COVID-19.
Hairfall after COVID-19 infection
Hair loss is evident in many patients who recovered from COVID-19 due to the vitamin deficiency, hormonal abnormality in the psychological factors like depression, anxiety may occur hair loss. Drugs used in the treatment of acute COVID-19 can lead to hair loss.25 The formulations such as Amalaki Rasayan, Amalak Ghrita, Triphala Rasayan which contains Phyllanthus emblica, Terminalia chebula, Terminalia bellerica highly effective for treating hair loss.
In this paper the rasayan which are commonly used in practise, and which are having potential to benefit the general population to tackle post COVID ailments, have been reviewed. Further research is necessary in this area. A list of rasayan for treating post COVID ailments or immune modulatory actions are summarized in theTable 2.
Discussion
Preparation of these awaleha or rasayan is carried out by specific processes. Details of these processes may be referred from the original Ayurvedic classic. Usually rasayan preparations involve many steps like heat, boiling, steaming, levigation, frying of the pulp of Amalaki or other fruits in ghee or oil, addition of aromatics herbs etc. Generally, process of manufacturing rasayan, avaleha are tedious. The choice of the rasayan is totally depend upon the age, strength, body constitution, disease condition of patients. E.g Lashun Rasayan, Bhallatak Rasayan are recommended for pitta prakiti individual and diseases, it is best choice for kaphaj prakriti and diseases. Even a normal person can consume suitable rejuvenating formula after consulting an Ayurvedic physician. If any complications occur due to intake of rasayan, it should be stopped immediately, and the diseases should be treated properly. There are no reports of any adverse drug reactions by common Rasayan formulations like Chyawanprash. (Charak Samhita 1/29. The main application of Rasayan formulations is rejuvenation of body tissues. Ayurveda proposes mild laxative drugs (bio-cleansing) before rasayan intervention. Charak Samhita mentioned only one preparation namely Haritakyadi powder for cleansing of the intestines before taking rejuvenation medicines. For best results of rasayan such intervention is needed, with consultation of Ayurvedic physician. Chyawanprash is widely used in COVID-19 pandemic as immunomodulation. Chyawanprash was extensively used by large number of patients during the COVID outbreak.
Table 2
Rasayan formulation for treating post COVID ailments.
AYUSH ministry had advised consumption of Chyawanprash for tacking COVID infections as a preventive and supportive drug. Ayurvedic classics advocate many rejuvenating formulas which can be used with consultation from Ayurvedic physicians for attaining strong immunity and tackling post COVID ailments.
Conclusion
The rejuvenation drugs like Chyawanprash can play a vital role in management of COVID-19 and its post infection ailments. There are long term symptoms which affect the COVID-19 patients. To prevent serious long term ailments, immunity boosting treatment and rejuvenating treatment of Ayurved can help. As the Ayurvedic drugs are natural, cost effective than modern medications.