Tiryaq is roughly translated as antidote or antivenom which is not only effective in diverse types of poisoning but also have other actions and uses. One of the famous Tiryaq is Tiryaq-e-arba. Tiryaq-e-arba is polyherbal pharmaceutical preparation consisting of four herbal ingredients due to which it is known as Tiryaq-e-arba as arba means four in Arabic. A unique feature of Tibbe Unani (Unani Medicine) is the possession of Tiryaqat roughly translated as antidotes which are not only effective in diverse types of poisoning but also have other important actions and uses. One of the most reputed Tiryaq is Tiryaq-e-arba (Ahmad M.H, 1913). Tirayq-e-Arba is a polyherbal Unani antidote formulation used in the management of poisoning due to snake bite, scorpion bite as well as in cold poisons since time immemorial. It is famous for its antidote action. It is reported to be brain tonic and cardiac tonic (Kabeeruddin, M, 1921; Jeelani, G, 1985), antidote (Attar A.N, 1329; Ghani, M.N, 1928), help in expulsion of dead foetus (Ghani, M.N, 1928; Shareef, M. 1873), liver corrective (Ghani, M.N, 1928; Antaki, D. 1930) and splenic corrective (Antaki, D. 1930; Rahman, S.Z, 1980). Classical text described its uses in biting of poisonous animals (Hasan M, 1893; Ali A.M, y.n.m), cold diseases (Hussain M.H. 1901; Ali A.M, y.n.m), cold poisons and cold oedema (Ghani, M.N, 1928; Hussain M.H. 1901), snake bite, scorpion bite, insect bite, spider bite (Ghani, M.N, 1928; Rahman, S.Z, 1980; Hasan M, 1893). As one of the aforeseen effect of animal bite is coldness and Tiryaq-e-arba temperament is hot in III^rd and dry in IV^th degree (Ghani, M.N, 1928; Shareef, M. 1873; Hussain M.H. 1901). So, it can be considered as best medicine to combat poisoning and coldness produced by it. As modern science also says that the efficacy of antivenom is its ability to bind venom components or toxins, while the effectiveness of antivenom is its ability to prevent or reverse the effects of envenoming in humans.

The antivenom activity of the test drug was studied by observing its effect on Plasma Fibrinogen level in Russell’s Viper Envenomation in rabbits by the method of Netelson (1971). The plasma fibrinogen level was found to be 171±665.04 mg/100 ml of blood, 36.18±1.12 mg/100 ml of blood, 33.14±0.52 mg/100 ml of blood and 17.9±1.65 mg/100 ml of blood at 0,1,3 and 6 hours respectively in control animals while in the test animal it was found to be 157.13±3.44 mg/100 ml of blood, 41.13±2.69 mg/100 ml of blood, 62.09±1.65 mg/100 ml of blood and 54.39±0.73 mg/100 ml of blood respectively as shown in table II. Further graphical presentation of effect of Tiryaq-e-arba on plasma levels after Russell’s Viper envenomation in rabbits is shown in Figure I.

Animal envenoming including snake, scorpion and other poisons are responsible for more than 20,000 deaths annually, making it one of the world’s most neglected tropical diseases according to the WHO. Venom-induced consumption coagulopathy (VICC) is a major effect of snake envenoming. Antivenom is the main treatment for VICC, but, although it appears to neutralize procoagulant toxins, clotting factor resynthesis and full recovery of clotting function takes 24–48 h. The prothrombin activators activate the clotting pathway and cause complete consumption of fibrinogen, factor V, and FVIII, resulting in unrecordable times for clotting tests (International Normalised Ratio [INR] and activated partial thromboplastin time), as well as very high D-dimer levels. (Isbister GK et al., 2013)

The diagnosis and monitoring of VICC requires coagulation studies and clotting times. Internationally, the most commonly used test is the 20-minute whole blood clotting test (WBCT20). However, the reliability of the WBCT20 as a diagnostic test has come into question for the diagnosis of Russell's viper envenoming. The duration of the WBCT ranges from 10 minutes in some studies to 30 minutes in others. (Yong Jun Jeon et al., 2019)

There are a number of proposed mechanisms by which the binding of antivenom to venom results in prevention or reversal of envenoming. Antivenom can potentially block the active site of a toxin or bind to a toxin to prevent it interacting with its substrate (steric hindrance) to neutralize the toxin. Antivenom-venom complex formation in the central compartment may prevent the distribution of toxins to the target tissues (e.g., nervous system) or cause the redistribution of toxins from their target tissues back to the vascular compartment. Antivenom can increase the elimination of toxins from the circulation and body. In the case of VICC, the toxins act in the central compartment, so antivenom must either bind to the toxins in the blood, and therefore prevent the action of the toxins, or increase the elimination of toxins.

Fresh frozen plasma appeared to speed the recovery of coagulopathy and should be considered in bleeding patients. Thus it is important to consider the proteolytic events of the proteinases on plasma proteins. In addition, most snake venom proteases affect coagulation by hydrolyzing the fibrinogen and inducing/prolonging clot formation. Several venom proteases with fibrinogenolytic activity have been reported and they preferentially hydrolyse Aα and Bβ subunits of fibrinogen. Similarly, T. malabaricus venom proteases hydrolyze Aα and Bβ subunits of human fibrinogen. Snake venom also contains prothrombin activators which cause a variable deficiency in factor V, VII and fibrinogen. (Kalana Maduwage and Geoffrey K. Isbiste, 2014)

In this study, the test animals were administered with 350 mg/kg of Tiryaq-e-arba by oral route once a day for 5 days while the control animals were administered with the vehicle i.e distilled water in the same volume and manner. Two hours after the last dose all the animals were injected with 2 mg/kg of Russell’s viper venom intra-peritoneally. Blood was collected at 0,1,3 and 6 hours later for the estimation of plasma fibrinogen by the colorimetric method of Netelson (1971). The test showed lower values at 0 hour than in the control animals but it was greater than in the control animals at 1,3 and 6 hours. The increases in plasma fibrinogen level in the test animals at 3 and 6 hours was statistically significant (P< 0.001) (Afaq SH, 1994). The significant results of increases in plasma fibrinogen level with increasing intervals revealed that Tiryaq-e-arba possesses significant antivenom effect.

Antivenom is the recommended standard treatment for snake envenoming. Antivenoms consist of polyclonal antibodies to the toxins in snake venoms. They may be whole immunoglobulins (IgG) or fractionated IgG, either F(ab′)2 or Fab. Tirayq-e-Arba is a famous antidote or antivenom of Unani Medicine which is used in the management of poisoning due to snake bite, scorpion bite etc. as well as by cold poison since time immemorial. But it was not evaluated scientifically before this study carried out, therefore it was studied for antivenom activity. The findings revealed that Tiryaq-e-arba possesses significant antivenom effect and scientifically support the Unani claim that it is Dafe-Sumoom-al-Hevan (Antivenom) and the use of this preparation in corresponding diseases. It can also be used as a unique emergency medicine where it is not possible to give modern emergency services immediately i.e., it can save one’s life. It may be used as an alternative to chemical antidotes and relieve the after effects of animal bite poisoning without side effects. Despite antivenom being efficacious and binding to the multiple toxins in the venom, there are a number of reasons that it may not be effective. For antivenom to be effective against such irreversible effects, it must be administered early, so it can bind with toxins before they distribute to their target sites and cause irreversible toxicity.