A Review of Literature on Punarnavadi Mandura : An Ayurvedic Herbo-Mineral Preparation

Background: Punarnavadi Mandura is an Ayurvedic herbo-mineral preparation primarily used as an anemia correcting agent while its role in other clinical conditions has also been studied. Objective: To understand the role of Punarnavadi Mandura in controlling anemia and other clinical conditions and its pharmacognostical and phytochemical properties. Methodology: A search of literature was carried out using “Punarnavadi Mandura” as the only key word and a total of 33 literatures were obtained of which 5 titles were finally selected for the review. Results and Discussion: Of the 5 studies identified 3 studies focused on the role of Punarnavadi Mandura as an anemia correcting agent, one study identified its role in other clinical condition (Diabetic Nephropathy), one study focused on the pharmacognostical and phytochemical analysis while one study focused on both the analysis of pharmacognostical and phytochemical properties and its role as an anemia correcting agent. As per these studies Punarnavadi Mandura is an effective remedy for iron deficiency anemia (IDA) of all ages. Statistically significant result has been obtained in subjective and hematological parameters. Furthermore its role in other clinical conditions has also been found effective, especially in Diabetic Nephropathy (DN), as a Naimithika Rasayana. Punarnavadi Mandura is currently a part of National health programme and is included in ASHA drugs kit for the management of IDA at community level. Conclusion: Given the efficacy of Punarnavadi Mandura in IDA, at all ages, its usage should be fostered more in Indian communities especially the rural communities where IDA is endemic.


INTRODUCTION
Punarnavadi Mandura is an Ayurvedic herbo-mineral preparation primarily used as an anemia correcting agent while its role in other clinical conditions has also been studied.2][3][4] The classical description of Punarnavadi Mandura is found in one of the major classics of Ayurveda, Charak Samhita.Acharya Charak has described the role of Punarnavadi Mandura as an anemia correcting agent in his classical treatise, Charak Samaita, in Chikitsa Stana. 5he ingredients described in Charak Samhita for the preparation of Punarnavadi Mandura have been delineated in Table 1.Furthermore a brief description of the preparation of Punarnavadi Mandura is described in Table 2. Punarnavadi Mandura act as an anemia correcting agent possibly by its effect on Srotosa (micro channels) and Agni (digestive fire mechanism) and thereby enhancing digestive capacity owing to Deepana (appetizer), Pachana (digestive) properties. 6In addition to anemia its role in other clinical conditions has been studied as well 7 Punarnavadi Mandura is being used for many other clinical conditions which include malabsorption syndrome, inflammation, splenic disease, intermittent fever, haemorrhoids, diseases of skin, and helminthiasis/ worm infestation. 5,8Furthermore Punarnavadi Mandura is currently a part of national health programme in India.It has been included in the ASHA drugs kit for the management of iron deficiency anemia (IDA) at community level in India.This drug has been included with the initiation of National Rural Health Mission (NRHM) in India under the aegis of "Mainstreaming of AYUSH and Revitalization of Local health Traditions" in India. 9,10With this background a review was carried out in order to understand the role of Punarnavadi Mandura in anemia and other pathological conditions.

OBJECTIVE
The main objective of this literature review is;

METHODOLOGY
A manual search strategy was adopted to obtain research papers on Punarnavadi Mandura.The search was primarily carried out using PUBMED and Google Scholar search engines and the only key word used for the purpose of search was "Punarnavadi Mandura" and was done deliberately in order to obtain research papers particularly on Punarnavadi Mandura only.A total of 33 articles were obtained by the end of this search process and 5 full texts articles were finally selected for the purpose of this review.Figure 1, shows the flowchart of selection of articles for the purpose of this review.

Inclusion and exclusion criteria
Articles published in English language only were included in the review.Furthermore original researches were only recruited for the purpose of review which precludes review articles and theoretical research.The studies those did not fall in these categories were excluded from review.

RESULTS
Of the 5 studies identified 3 studies (n=5) focused on the role of Punarnavadi Mandura as an anemia correcting agent (Table 3), 1 study (n=5) identified its role in other clinical condition (Table 4), 1 study (n=5) focused on the pharmacognostical and phytochemical analysis while 1 study (n=5) focused on both the analysis of pharmacognostical and phytochemical properties (Table 2) and its role as an anemia correcting agent.

DISCUSSION
Punarnavadi Mandura is an effective herbo-mineral preparation for the management of Iron deficiency anemia (IDA).Furthermore it was observed that this drug is effective in IDA among all age groups; pediatric, geriatrics and adult age groups. 6,12,13Studies also reveal that this drug is well tolerated among the patients without any side effects and untoward effects compared to allopathic drug in one of the clinical trials. 12One of the advantages of Ayurvedic preparations is that most of these drugs are administered with some vehicle which improves the efficacy of the parent drug and Punarnavadi Mandura is not an exception to this principle.Punarnavadi Mandura is preferably administered with butter milk which is acidic pH and contains lactic acid.Iron absorption is aided by decreased pH. 14Furthermore it may also possible that iron combines with lactic acid to form ferrous lactate before absorp-tion.Modern medical system uses ferrous lactate for the management of Iron deficiency anemia. 15Alternatively it may also happen that the proteins of butter milk or the amino acids released after digestion may combine with iron before the absorption takes place.This point of view is also supported by the World Health Organization as it supports the use of meat and other proteins for the absorption of iron. 16However, Ayurveda has a different view on the role of Punarnavadi Mandura in controlling anemia which is primarily directed towards Agni (Digestive fire). 6But this concept is also indirectly related to the mechanism of absorption of iron in the gastro-intestinal tract by the process of Deepana and Pachana. 6,17he study that focused on geriatric anemia has offered a probable explanation of the action of Punarnavadi Mandura among geriatric patients suffering from anemia.Triphala, Trikatu, Chitraka, Vidanga and Pippalimula have appetizer, digestive and carminative properties which improves digestive power and ultimately absorption of the drug.The components like Trivrita, Haritaki and Danti act as laxative which help in relieving constipation mainly found in old age.Haridra, Amalaki, Pippali, Punarnava and Trivrita were mentioned as Panduhara (antianemic) by various Acharyas.Amalaki, Danti, Pippali, Punarnava, Kushtha and Daruharidra are documented as drugs which are having immunomodulator and antioxidant properties having the potential of providing beneficial health effects in geriatric anemia. 6harmacognosy Journal, Vol 8, Issue 3, May-Jun, 2016

Laboratory Investigation
Punarnavadi Mandura vati was prepared by the following process and its phramacognostical and pytochemical analysis was carried out.The ingredients mentioned in Table 1, were cleaned, dried, powdered and passed through sieve number 85. Mandura bhasma was mixed with cow urine and heated.5% of gum acacia was mixed as binding agent.The mixture was converted in to granules and then punched in to 500 mg tablets by tablet making machine.
The organoleptic assessment shows that Punarnavadi Mandura vati is light reddish brown in color, gomutra gandhi (smells like cow urine), Astringent-bitter in taste and solid in consistency with rough surface.
Physiochemical parameters-water soluble extract and methanol soluble extract were found to be 13.09% w/w and 6.37% w/w respectively.

Laboratory Investigation
The powdered drug was first ashed in a muffle furnace and the residue was digested in aquaregia.The volume of the extract was reduced by boiling and then diluted by deionised water.The minerals-iron, copper, zinc, calcium and magnesium were determined by atomic absorption spectrophotometry, while sodium and potassium were in flame photometer.The analysis of carbon, hydrogen and nitrogen was done by RSIC of Central Drug Research Institute, Lucknow.
Amalaki is a rich dietary source of Vitamin C, a powerful water-soluble antioxidant, helps in increasing iron absorption from the gut. 18One of the studies on Pippali suggests that, piperine gets absorbed very quickly across the intestinal barrier through the intracellular pathway.It may modulate membrane dynamics owing to its easy partitioning properties thus helping in efficient permeability across the barriers.In addition Pippali is said to be bio-availability enhancer of drug, further helping in easy assimilation of the drug components. 19andura Bhasma (incinerated form of iron-Fe 2 O 3 ), by virtue of Rasa and Guna, pacifies aggravated Pitta and maintains the normalcy thereby improving the digestion and metabolism.The ferric and ferrous fractions of Mandura provide sufficient iron needed for normal erythropoiesis. 20urthermore the presence of erythropoietin hormone in cow urine helps in the improvement of anemia. 21 addition to the anti-anemic properties of Punarnavadi Mandura, it is also found effective in other clinical conditions, such as Diabetic nephropathy, as reported by one of the studies. 7The study reported that the combination of Shilajatvadi Vataka, Punarnavadi Mandura, Pippali Mooladi Paneeya-along with Amrita and Bringaraja and Triphala Guggulu acted as a Naimithika Rasayana and helped in managing Diabetic nephropathy. 7Naimithika Rasayana is a unique concept described in Ayurveda which promotes vigor and vitality and instills the ability to hold out disastrous outcomes of diseases. 22,23

CONCLUSION
As per different studies Punarnavadi Mandura is effective against Iron deficiency anemia at all ages.Studies also reveal that it is well tolerated among patients without any side effects and untoward health effects  15 patients of either sex with Diabetic Nephopathy, aged between 20 and 80 years, were administered with a compound preparation containing Shilajatvadi Vataka-6 g twice daily in empty stomach with 100 ml of milk, Punarnavadi Mandura-2 g, 3 times a day after food, Pippali Mooladi Paneeya-along with Amrita and Bringaraja-30 ml, twice a day, before food, Triphala Guggulu-3 g, twice a day, after food for 48 days.
There was symptomatic improvement in Pada Shotha (pedal edema), Akshikoota Shotha (retroorbital edema).Statistically significant improvement was observed in Agni (gastric fire) status.Significant improvement was observed in micro-albuminuria in which the difference of pre and post test mean of 83.76 μg/24 h was observed hence the same can effectively be used for IDA.Moreover Punarnavadi Mandura is also more efficacious compared to allopathic hematinics as per one of the studies.The use of this drug under national health programme in India also proves its efficacy in managing the IDA at community level especially in rural India.Hence this drug can be effectively used in rural India where the prevalence IDA is rampant.

Figure 1 :
Figure 1: Flowchart showing the selection of articles for review.