1. INTRODUCTION
The concept of 'Agni’ (metabolic fire) in Ayurveda is a unique approach to the understanding of the physiology of digestion and metabolism. The 'Agni' (metabolic fire) is closely aligned to the entity of Pitta Dosha (the heat energy in the body) Hypo functioning of Agni results in incompletely formed products of metabolism referred to as 'Ama'. Thus 'Ama' is the product of faulty digestion resulting due to 'Mandagni' i.e. hypo functioning of 'Biofire'. As per Ayurvedic medicine, it possesses the properties of Visa or toxin and is responsible for various local and systemic illnesses and the classical text compares Amavisato an acute state of poisoning. Ama also refers to such intermediate or byproduct of metabolism that tends to cause a blockage within the microchannels of the body i.e. 'Srotovarodha'. Thus Ama is a very important morbid factor responsible for various local and systemic diseases. At systemic level i.e. at the level of body tissues, hypo functioning of Dhatwagni (metabolic fire at tissue level) causes inadequate tissue metabolism leading to prolonged accumulation of a variety of morbid products i.e. Ama, in the system, which are responsible for different kinds of systemic diseases like Amavata (Tripathi JS, Singh RH, 1999).
Amavata is a local as well as systemic disorder inflammatory in nature caused due to association of Ama with vitiated Vata (subtle energy associated with movement). Poor dietary habit and faulty Dincharya (daily regimen) and Rritucharya (seasonal regimen) leading to deranged metabolism and Agni which results in the formation of Ama (undigested product of metabolism), at the same time the vitiation of Vatadue to Vatavardhakanidana (etiological factors increasing energy associated with movement) like strenuous exercise immediately after consumption of fatty foods takes place and when Ama conceals with vitiated Vata and circulates in the body under the influence of Vyanavayu (“omnipresent air,”) it clogs the Srotasas (microchannels) and initiates the inflammatory cascade thus resulting in local/systemic illness (Aswathy YS, Anandaraman PV, 2019).
Studies proved that free radical-damaged cellular material is involved in the production of Ama. Free radicals and reactive oxygen species (ROS) are unstable molecules produced as a by-product of cellular metabolism if produced in excessive amounts, these reactive molecules cause extensive damage. Similarly, Ama is the intermediate product of hypo functional Agni. Neutralization of the free radicals and ROS contributing to the Ama production is necessary at the same time eradication of accumulated Ama from the body and restoration of optimal health is also needed (Sharma H, 2009).
1.1 Gut microbiota and rheumatoid arthritis
There are trillions of bacteria in human intestine. These commensal flora coevolved with the host are involved in numerous metabolic functions. Microbial colonization occurs before birth and it keeps on changing. The diversification depends upon the environmental factors, dietary habits, and medications. Thus the modulation of GM through diet, drug, and therapies like Virechana (therapeutic purgation) may change the clinical outcome. Most of the research work done in the field of rheumatoid arthritis has focused on genetic factors, but the host microbiota, and especially the gut microbiota (GM), has a key role in the etiopathogenesis of RA. Microbial composition of new-onset untreated RA (NORA) in comparison to healthy subjects has an abundance of Prevotellacopri with reduced level of Bacteroides in RA patient. Moreover, the gut Dysbiosis in RA patients were suggestive of depletion of gram-negative bacteria while gram-positive bacteria were more in number. Overall the gut microbiome Dysbiosis is associated (Bodkhe Ret al., 2019).
1.2 Gut microbiota and autoimmunity
The role of environmental factors, genetic predisposition, and disturbed gut flora has been the source in the development of autoimmune diseases like rheumatoid arthritis, psoriasis, multiple sclerosis, type1 diabetes mellitus, etc. Since birth, GM has a significant impact on the host immune system. Exposure to the microbial component leads to the development of immune response in the newborn baby and these encounters to microbial and environmental factors develops the adaptive immune behaviour. quantitative and subjective changes in the arrangement of the gut microbiome could prompt obsessive Dysbiosis and have been identified with an expanding number of diseases. The process of autoimmunity is insidious and develops over time but preclinical symptoms precede the clinical ailment much before and can be detected through pathological investigations such as peripheral blood smear detecting autoantibodies. The early symptoms of autoimmune disorders are not well defined and arises as easy fatigability, low-grade fever, muscle, and joint aches, and malaise. These symptoms get debilitating once the disease establishes with significant morbidity. In this way we see that control colonization and safe manipulation of GM can be a key to control the disease aggravation and progression and therefore our traditional medical system of Ayurveda turns out to be amazingly applicable where the accentuation is given on Aahar (food can change the composition of gut flora), Vihar (daily and seasonal regimen influences the microbiome), and Vichar (point of view influences the immune response) to manage the issue of autoimmunity (Bharti, Sujitet al.,2019).
1.3 Why alternative medical procedure or alternative medicine is needful in the present condition?
The treatment targeting at the neutralization of the free radicals, management of symptoms, and boosting the Agni (metabolic fire) such that the symptoms gets alleviated is called as Shaman Chikitsa (conservative management). While the eradication of the accumulated Ama is taken care by Shodhanachikitsa (biological purification of the body) of which Virechana (therapeutic purgation) is a type (Gupta SK et al., 2015).
Ayurvedic classics quote the symptoms of Amavata as body ache, lack of taste, thirst, laziness, feeling of heaviness, fever, indigestion, and generalised body swelling. When the Amavata aggravates then it is difficult to treat and enters the Shlesmasthana (especially synovial joints of the body) and manifest as painful swelling of the afflicted joint. The intensity of pain is too much that it is compared to scorpion sting (MadhavNidana 25/6-7).
3. DISCUSSION
3.1 How Dysbiosis generate <italic>Ama</italic>?
Dysbiosis (mainly Dysbacteriosis) is the microbial imbalance inside the body. Dysbiosis is most commonly reported as a condition in the GIT during SIBO (small intestine bacterial overgrowth) or SIFO (small intestine fungal overgrowth). It is accompanied by a decrease in the ability to check each other growth and which results in the overgrowth of one or more of the disturbed colonies of microbes. Microbial colonies excrete waste byproducts which are removed by the body by normal removal mechanism but inappropriate large colonies excrete larger amount of byproducts hence the body is unable to remove this much so there will be the accumulation of these morbid matters inside the body. This gives birth to an idea called as Malasanchayajanya Ama (metabolic intermediate gets deposited and acts as a toxic substance) Gut flora helps in digestion and metabolism via secreting useful chemicals and another mechanism so when the Gut environment is altered then the metabolism and assimilation is disrupted so more and more Ama is produced and a vicious cycle of Ama production is started in the body leading to many disorders. Gut flora helps to protect the body from pathogenic infiltration and Dysbiosis increases the number of harmful bacteria in the gut hence immune dysfunction occurs.
Several mechanisms are involved in Gut microbiota alterations leading to an autoimmune response. Autoimmune disease pathogenesis due to Dysbiosis occurs via Epigenetics, molecular mimicry, and decrease immune tolerance, post-translational modification of host proteins, and polarization towards inflammatory phenotypes as well as induction of intestinal permeability (Zyanya Reyes et al., 2020).
Various studies established the fact that the gut microbiota has a profound effect on the host immune system and can affect autoimmune-related diseases. Commensals residing in the gut keep maintaining essential health benefits to the host. But when the gut microbiota homeostasis is disturbed because of overuse of antibiotics and other environmental factors causes Dysbiosis leading to numerous health disorders and immune deregulation, leading to autoimmune disorders (Wu HJ, Wu E,2012).
3.2 Role of Virechana (Therapeutic purgation) in <italic>Amavata</italic>
Treatment guidelines mentioned about Amavata depicts stage-wise treatment. The treatment protocol in Amavata includes Langhana (fasting), Swedana (sudation), use of Tikta Rasa (bitter)/Katu Rasa (pungent) Pradhanadravyas, with respect this all leads to Agnideepana and Amapachana (ignition of metabolic fire and pacification of Ama) once the Ama state gets converted into Nirama (non toxic) state the Ama accumulated in the bodily tissues is expelled out of the body through medicated bowel cleansing. In the context of Amavata chikitsa for bowel cleansing, virechana has been used. In texts, Virechana is mentioned as the treatment in cases like Pittajavikara, Amajanyaroga, Udararoga and Udavartaroga Although Virechana is the best remedy for Pitta dosha, yet it is effective in the vitiated Kapha and Vatadosha to some extent. Symptoms like Aanaha,Vibandha, Antrakujana, Kukshishula, etc. are indicative of Pratiloma Gati of Vata which are best conquered by Virechana, It removes the Avarana produced by Kledaka Kapha, and pacifies the vitiated pratilomavayu (Godbole, Amritet al., 2018).
Proper virechana karma leads to clearance in all the Srotasas (channels of body), freshness in the sense organs, lightness in the body, improvement in Agni (metabolism) and attains disease-free status (CarakaSamhita, Siddhi Sthana, 1/17).
Improvement in the status of Agni brings out improved health status, enhancement of Ojas, and improved quality of life. Agni is supposed to be the pillar upon which the health and longevity of a person are dependent. When the Agni is not in equilibrium, i.e. either Tikshna (hyperfunction) or Manda (hypofunction) or Vishama (sometimes hyperfunction sometimes hypofunction) the state of normalcy is disturbed and the individual suffers from various diseases and if Agni stops functioning, it leads to death of the individual. Hence, the Agni is alleged to be the basic reason for health and longevity (CarakaSamhita, ChikitsaSthana, 15/3-4).
3.3 Role of bowel cleansing in Dysbiosis
There are various studies in various databases advocating the role of purgation on the intestinal microbiota. One such study showed the instant and substantial change to the intestinal microbiota following purgation. The total microbial load was decreased by 31-fold and the colonisation of the bacteria was restored after fourteen days. Four stool samples were collected from the participants. These incorporated a baseline test gave a day before the bowel cleansing, one following the lavage, and two follow-up tests 14 and 28 days after the bowel cleansing. The faecal microbial DNA was separated and the microbiota was examined by utilizing a phylogenetic microarray. The phylogenetic microarray was enhanced with quantitative PCR (qPCR) investigation of the all-out microbes and methanogenic archaea. The number of microscopic organisms in the samples following bowel preparation was approx 34.7-fold (p<0.001) lower than in the baseline faecal samples. Likewise, the quantities of methanogenic archaea per gram of stool sample were reduced. The number of bacteria was re-established to the baseline levels following 14 and 28 days. Likewise, the microbiota profiles demonstrated a noteworthy reduction during the bowel cleansing in comparison to the baseline (Jalanka Jet al., 2015). The study adds to the Ayurveda concept of Virechana and Samsarjan Karma (specific diet post bowel cleansing) where Virechana Karma cleans the bowel off the morbid matters as well as would help in correction of dysbiosis while Samsarjan Karma restores the Agni to its normal level and would establish eubiosis.