Global J Res. Med. Plants & Indigen. Med. | Volume 2, Issue 1 | January 2013 | 52–64 ISSN 2277-4289 | www.gjrmi.com | International, Peer reviewed, Open access, Monthly Online Journal

Research article A COMPARATIVE CLINICAL EVALUATION OF THYROMAX POWDER AGAINST THYROXINE SODIUM IN THE MANAGEMENT OF HYPOTHYROIDISM Ujjaliya Nitin1*, Krishnankutty S V2, Remadevi R3 1

Assistant Prof., Dept. of Dravyaguna Vijnana, Shri Dhanwantry Ayurvedic College & Dabur Dhanwantry Hospital, Chandigarh, India 2 Head, Department of Internal medicine, Maulana Hospital, Perinthalmanna, Kerala, India 3 Prof. & Head, Dept. of Dravyaguna Vijnana, V.P.S.V. Ayurveda College, Kottakkal, Kerala, India *Corresponding Author: Email: [email protected]

Received: 06/12/2012; Revised: 01/01/2013; Accepted: 07/01/2013

ABSTRACT The thyroid gland regulates metabolism of the body by virtue of its hormones. Insufficient levels of thyroid hormone causes signs and symptoms such as slower metabolic rate, weight gain, sleepiness, dry and cool skin, as well as others. This condition collectively can be called as Hypothyroidism. Of the different types, Primary Hypothyroidism is the commonest which occurs after destruction of thyroid follicles mainly because of autoimmunity. Hypothyroidism is most common in women than men. According to a study, it affects 3.9% people with 9.4% subclinical condition. The sole available treatment for this in conventional science is Hormone Replacement Therapy which is not always free from side effects and has to be taken lifelong. This study was aimed to search an option for Hypothyroidism in terms of herbs. Traditionally practiced drugs Guducī Satvam (Tinospora cordifolia Miers.) and Āmalakī cūrnam (Phyllanthus emblica Linn.) was taken in a combination named „Thyromax powder’ which was standardized before commencing with clinical trial. A controlled clinical trial was planned with 20 newly diagnosed participants, which were not exposed to any medicament, with Thyroxine sodium in control group and Thyromax powder in study group for the duration of 3 month. Assessment was done on the basis of six subjective parameters and thyroid function test. Statistically, study drug showed a positive correlation on subjective parameters while control group showed significant result on T3 and T4 levels. Both the groups were found statistically insignificant on TSH level. KEY WORDS: Thyromax powder, Hypothyroidism, Standardization, controlled clinical trial.

Cite this article: Ujjaliya Nitin, Krishnankutty S V, Remadevi R (2013), A COMPARATIVE CLINICAL EVALUATION OF THYROMAX POWDER AGAINST THYROXINE SODIUM IN THE MANAGEMENT OF HYPOTHYROIDISM, Global J Res. Med. Plants & Indigen. Med., Volume 2(1): 52–64

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INTRODUCTION Endocrinology concerns the synthesis, secretion and action of hormones. Hormones are chemical messengers which have diverse molecular structures and are related to endocrine glands thereby coordinate the activities of different cells. Some endocrine disorders are common, particularly those of the thyroid gland. At present thyroid diseases form the second most common endocrine disorder in India next to Diabetes mellitus. (Sir Stanley Davidson, Davidson Principles & Practice of Medicine; 2006). According to the report of N. Kochupilli, thyroid disorders (5.4%) are the most common among all the endocrine diseases in India (N. Kochupillai et al., 1986). Unfortunately many people may have this disease and even not realize it. According to a study known as a “Colorado thyroid disease prevalence study” there may be as 13 million Americans with an undiagnosed thyroid condition (Gay J Canaris et al., 2000). In the state of Kerala, India, 9.4% people who suffer from hypothyroidism are asymptomatic (Unnikrishnan AG et al., 2011). Wickham Survey suggested that there is a high possibility of developing Hypothyroidism in the population with raised TSH and thyroid antibodies. In the after follow up study it was demonstrated to be much accurate. It was inferred that increasing values of serum TSH above 2mU/l increases the probability of developing hypothyroidism which was further increased in the presence of anti-thyroid antibodies (Vanderpump MP, 1995). According to a study anti-thyroid antibodies were found in 89.6% of the women between 15–35 years of age and the overall prevalence of classical Hypothyroidism was found to be 10 times more than the men (K.P. Paulose, 2011). This made the medical society to consider it with a higher importance, as it may result in severe complications. The possibility of incidence of the disease also increases with a higher rate in old age. In Hypothyroidism, body function decreases and this leads to a slow heart rate, an increase in cholesterol level, mild anemia, pervasive fatigue, depression, low body

temperature, cold intolerance, coarsening of skin, muscles and joint aches, constipation, weight gain, slow hair growth, loss of libido, infertility, increased risk of miscarriage and irregular menstrual cycle in women etc. In the most common case of Hypothyroidism, namely Primary Hypothyroidism resulting from an intrinsic disorder of thyroid gland, serum T3 and T4 is low and TSH elevated also called as classical Hypothyroidism, resulting above signs and symptoms. (Sir Stanley Davidson, Davidson Principles & Practice of Medicine; 2006). According to the signs and symptoms, it is concluded that Hypothyroidism is a resultant of Vāta-kapha-medo vikrti and Dhātvāgnimāndhya (Alsa mariyam kalathancheri, 2008 and Chanchal Gupta, 2003). Guducī and Āmalakī are known for Rasāyana property and have action on Dhātvāgni specially Rasa and Rakta. Both the drugs have been proven as immunomodulators and anti-oxidant effects. (Dikshit V et al., 2003 and Shukla V et al., 2009). Prevalence of autoimmune Hypothyroidism is much higher (K.P. Paulose, 2001). Considering rejuvenative effect of these herbs, they may rejuvenate destroyed follicles of thyroid gland which are responsible for production of thyroid hormones; of course it is questionable and needs further research. These are proved drugs for many diseases and found non toxic. These two drugs are not found to have any drug interactions. (Database on Medicinal Plants used in Ayurveda, 2005). Guducī Satvam (extract of Tinospora cordifolia Miers.) along with Āmalakī cūrnam (powder of fruit of Phyllanthus emblica Linn.) is used by the traditional vaidyas for Hypothyroidism in Madhya Pradesh and found effective. In modern medicine hormone supplement is the only management for this disease. Though it is thought to be a successful therapy but a long term hormone therapy is not always free from complications as well as side effects. Most often it is needed to continue throughout the life in adjusted doses.

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This study was an effort to evaluate the effect of these two drugs in a combination which is named as “Thyromax powder” on the clinical symptoms and T3, T4 and TSH levels of Hypothyroidism.

standardization of drug and extraction of plant constituents. (Quality Standards of Indian medicinal Plants, and The Ayurvedic Pharmacopoeia of India, 2001). (Table no. 2 4)

MATERIALS AND METHOD

Phytochemical analysis

Study design

Quantification of characteristic compounds

The study design was a controlled clinical trial. Randomization was not done due to two different settings. Newly diagnosed participants were selected as per the inclusion and exclusion criteria. The control selected here was not a concurrent control. The control group was selected from an accessible population at Maulana Hospital, Perinthalmanna, Kerala, India. A detailed clinical examination was done before and after the study using a prepared case record form. Analysis of both the treatments was done by evaluating subjective and objective parameters.

The extracts obtained were subjected to qualitative tests for the identification of various plant constituents. (Quality Standards of Indian medicinal Plants, 2003 and The Ayurvedic Pharmacopoeia of India, 2001). (Table no. 5 7)

Sample collection and preparation of study drug The fresh Stem of Tinospora cordifolia were collected from nearby areas of Kottakkal, Kerala, India. The stem cuttings were properly identified in the department using external morphological and histological characters. Satvam was prepared as per the procedure given in the text. (Yogaratnākara Rājayaksamā Cikitsā; 328, Verse no. 1-11/2) The fresh fruit of Phyllanthus emblica of similar size were bought from market. The fruits were identified in the department and well dried in shade. Powder was prepared in the size of 40–80 microns. (The Ayurvedic Pharmacopoeia of India, 2001) Physicochemical Thyromax powder

Standardization

of

In the present study the combination of Satvam of Tinospora cordifolia and fine powder of dried fruits of Phyllanthus emblica in the ratio of 1:3; given the name Thyromax powder were subjected to preliminary physicochemical screening for the

Thin Layer Chromatography & HPTLC Selection of chromatographic layer Pre-coated TLC silica gel 60 F254 (E. Merck) plates on aluminum sheet were used for chromatographic profile for individual drugs and for Thyromax powder. TLC of all successive solvent extractives of Thyromax powder was prepared. While HPTLC fingerprinting of methanolic extract of Guducī Satvam, Āmalakī cūrnam and Thyromax powder was prepared. Selection of mobile phase for TLC a] For Thyromax powder Before the application of the samples to the plates, an appropriate solvent system was selected. The solvent system was chosen by the trial and error method. The solvent systems used for the TLC analysis were different for different successive solvent extractives.  For Petroleum ether extract – n-hexane : ethyl acetate : formic acid (10:2:0.2)  For Cyclohexane extractive – Toluene : ethyl acetate : formic acid (8:2:0.2 )  For Acetone & Ethanol extract – Toluene : ethyl acetate : formic acid (5:5:1) Selection of mobile phase for HPTLC a] For Guducī Satvam  For methanolic extract – toluene : ethyl acetate : formic acid (7:5:1)

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b] For Āmalakī cūrnam  For methanolic extract – toluene : ethyl acetate : formic acid (7:5:1) c] For Thyromax powder  For methanolic extract – toluene : ethyl acetate : formic acid (7:5:1) Application of sample For the application of sample CAMAG Automatic TLC sampler IV were used and the concentration of sample extractives were between 0.2 to 0.6 micro liters. Pre-conditioning Saturated chamber by lining with filter paper for 30 minutes was prepared prior to development for getting better Rf values. For this CAMAG ADC-2 Automatic development chamber was used. Chromatographic development and drying After development, the plates were taken out and mobile phase was completely removed from the plate by drying in vacuum desiccators. Detection and visualization Detection under UV light is the first choice so plates were visualized in CAMAG TLC Visualizer and photographs were taken in UV 254 and 365 nm. wavelength. Since very dim spots were obtained in visible light, the TLC plates were then sprayed with Anasaldehyde sulphuric acid and dried in hot air oven at 110oC. The colors of the spots were recorded and their positions were marked. The distance travelled by each band was measured and respective Rf values were calculated. TLC analysis of Thyromax powder For TLC study of Thyromax powder, Petroleum ether, Cyclohexane, Acetone and Ethanol extractives were spotted in the solvent system given in the literature of TLC under heading selection of solvent system. Eluents were different for all extractives (common for Acetone and Ethanol) hence Rf values, TLC photographs are given separate.

HPTLC analysis HPTLC profile was prepared for Guducī Satvam, Āmalakī cūrnam and for the combination Thyromax powder separately. The mobile phase and extracts were different for samples and has been mentioned earlier. For Methanolic extract of Guducī Satvam and Āmalakī cūrnam table of Rf value, TLC plate photos and HPTLC over view and area graphs are given separately. Clinical study In the present study randomization was not done hence comparison of demographic details and base line values of both the groups were done. Comparison of response to the treatment within both the groups was done. Total 20 participants were registered for the present study, each 10 in study and control group. All participants received full course of treatment and completed their course successfully without any interruption, hence there were no dropouts in the study. Data outcome were tabulated; mean deviation, standard deviation and percentage between the assessments were calculated. Student „t‟ test was applied to find out level of significance for all the parameters with in the treatment and control group. The data were statistically analyzed before and after intervention. RESULTS Organoleptic characters Detailed in (Table 1) Powder microscopy Guducī satvam Starch grains of Guducī showed deep blue color when mounted with Iodine solution. Every particle of Satvam was separated from each other. The shapes of Satvam particle was not similar and varies in size from other particles. Starch grains of Guducī were approximately 5.5–11.20µ in diameter and 6– 11.28µ in length. (Fig. no. 1&2).

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Powder microscopy of Āmalakī cūrnam Powder showed hexagonal, thick, straightwalled epidermal cells in surface view embedded with small prismatic crystals of silica; isolated or groups of thin-walled pitted stone cells; fragments of thick walled fibers and

sclereids; fragments of pitted vessels, tracheids and parenchyma, crystals of silica and simple oval to spherical starch grains scattered as such or embedded in the parenchymatous cells of the mesocarp. (Fig.no.3-6) (The Ayurvedic Pharmacopoeia of India).

Table 1. Organoleptic Characters No. Characters Characteristics of Satvam Characteristics of Āmalakī cūrnam Touch Fine and Smooth Rough 1 Color White Light grey 2 Taste Sweet Bitter, Sour and Sweet astringent 3 Odor Odorless Odorless 4 Consistency Fine powder Fine powder 5 Fig. 1–2 Powder Microscopy of Guducī Satvam

Fig. 3–6 Powder Microscopy of Āmalakī Cūrnam

Table 2. Physicochemical standards of Thyromax powder Sr. No. 1. 2. 3. 4. 5. 6.

7.

Experiments Total ash Water insoluble ash Acid insoluble ash Moisture content Volatile oil content Sugar content a. Total Sugar b. Reducing sugar Fibre content

Percentage 3.05% 2.23% 1.47% 11% 01% 13.1% 7.23% 3.0%

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Table 3. Percentage of water soluble and alcohol soluble extractives No. Name of extract Percentage of extract Color / Consistency 1.

Hot water soluble

80.75%

Blackish brown / Dry

2.

Cold alcohol soluble 27.40%

Dark brown / Oily

3.

Hot alcohol soluble

Dark brown / Oily

50.00%

No.

Table 4. Successive solvent extractives Experiments Percentage Color /Consistency

1. 2.

Petroleum ether Cyclohexane

1.63 % 0.80 %

Light yellow / Oily Lemon yellow/Oily

3. 4.

Acetone Ethanol

12.0 % 11.0 %

Dark brown / Oily Dark brown / Oily

Table 5. Qualitative Phytochemical analysis of the extractives Solvent Steroid Alkaloids by Phenol Flavonoids Tannins Mayer’s DDR Petroleum ether Cyclohexane Acetone Ethanol Water Cold alcohol Hot alcohol

– + – – – – –

+ – + + + + +

+ + + + – + +

– – + + + + +

– – + + + + +

+ + + + + + +

Table 6. Rf values of different spots of Thyromax powder ether Cyclohexane Acetone extract Ethanol extract extract 5 Spots 3 Spots 7 Spots

Petroleum extract 7 Spots Colour of Rf Spot 0.24 Violet

Colour of Spot

Rf

0.40

Colour of Rf Spot Brown 0.12

Pale brown

0.07

Colour of Spot Purple

Rf

Violet

0.31

Purple

0.48

Brown

0.34

Pale brown

0.13

Violet

0.36

Purple

0.66

0.46

Pale brown

0.17

Violet

0.40

Violet

0.78

Light violet -

-

Pale brown

0.24

Pale pink 0.61

Violet

0.88

-

-

Brown

0.35

Violet

0.68

-

-

-

-

Light green

0.41

Pale Violet

0.80

-

-

-

-

Light violet

0.49

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TLC of Thyromax powder (Fig. no. 7-18) Fig. no. 7- 9: TLC plate of Petroleum ether extract of Thyromax powder Fig. no. 10- 12: TLC plate of Cyclohexane extract of Thyromax powder

7: 254 nm

8: Derivatized plate.

9: 366 nm.

10: 254 nm.

11: Derivatized plate.

12: 366 nm.

Fig. no. 13- 15: TLC plates of Acetone extract of Thyromax powder Fig. no. 16- 18: TLC plates of Ethanolic extracts of Thyromax powder

13: 254 nm

14: Derivatized plate.

15: 366 nm.

16: 254 nm.

17: Derivatized plate.

18: 366 nm.

Table 7. Rf value details of Methanolic extract of Guducī Satvam, Āmalakī cūrnam and Thyromax powder. Guducī Satvam Āmalakī cūrnam Thyromax powder Spots Color

Spots Rf

Color

Light orange 0.80 Blue

Spots Rf

Color

0.18 Dark blue

Rf 0.18

Light orange 0.40 Blue

0.60

Light violet

0.70 Pink

0.70

Pink

0.80

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TLC of Āmalakī curnam and Guducī satvam (Fig. no. 19-23) Fig. no. 19- 21: TLC plates of Methanolic extract Fig. no. 22- 23: TLC plates of Methanolic extract of Thyromax powder.

19: Āmalakī at 254nm

20: Āmalakī at 366nm

21: Guducī at 366nm.

22: 254 nm

23: 366nm

HPTLC Over view graphs of study drugs (Fig. no. 24-31) Fig. no. 24: Over view graph of Methanolic extract of Āmalakī at 254nm Fig. no. 25: Area graph of Methanolic extract of Āmalakī at 254 nm.

Fig. no. 26: Over view graph of Methanolic extract of Guducī Satvam at 254 nm Fig. no. 27: Area graph of Methanolic extract of Guducī Satvam at 254 nm

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Fig. no. 28: Over view graph of Methanolic extract of Thyromax powder at 254 nm Fig. no. 29: Area graph of Methanolic extract of Thyromax powder at 254 nm

Fig. no. 30: Over view graph of Methanolic extract of Thyromax powder at 366 nm Fig. no. 31: Area graph of Methanolic extract of Thyromax powder at 366 nm

Data related to response to the treatment Graph 1. Effect of the treatment on weight gain

Graph 2. Effect of the treatment on excessive sleep

Effect of the treatment on weight gain 1.2 1.3 1.4 1.2 1 0.8 0.6 0.4 0.2 0

Effect of the treatment on excessive sleep 2.2

1.2

0.3

Study Control

2.5 2 1.5 1 0.5 0

1.6 0.2

Study Control

BT BT

1.9

AT

AT

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Graph 3. Effect of the treatment on muscle cramp

Graph 4. Effect of the treatment on edema

Effect of the treatment on muscle cramp 3

2

2.2 2.0

1.7

1.5

Effect of the treatment on edema 1.8 1.3 1.1

2

Study

0.2

1

Control

0

0.4

1

Study Control

0.5

0 BT

AT

BT

Graph 5. Effect of the treatment on dry skin

Graph 6. Effect of the treatment on constipation

Effect of the treatment on dry 2.0 skin 2 1.8 1.6 1.4 1.2 1 0.8 0.6 0.4 0.2 0

1.5

3

1.4

AT

2.5

Effect of the treatment on 2.8 constipation 2.4 2.1

2

0.6

Study Control

Study

1.5

Control

1

0.0

0.5 0 BT

AT

BT

AT

Graph 7. Effect of the treatment on T3 parameter

Graph 8. Effect of the treatment on T4 parameter

Effect of the treatment on T3 parameter

Effect of the treatment on T4 parameter

1 0.8 0.6 0.4 0.2 0

0.822 0.696 0.658 0.719

Study Control

BT

AT

70 60 50 40 30 20 10 0

54.01

54.91 65.92

Study

43.76

Control

BT

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AT

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Graph 9. Effect of the treatment on TSH

Effect of the treatment on TSH 62.79 70

55.99

60 50 40

23.46

30

Study Control

8.17

20 10 0 BT

DISCUSSION Pharmacognostical study Moisture content of the shade dried drug determined by Dean & Starks apparatus was found to be 11%. Total ash of any drug is the residue obtained on its complete incineration in an electric Bunsen burner. This mainly represents the inorganic salts present in the drug, if the drug is pure and any impurities like sand, soil etc. adhering to the drug will also remain as ash, thus increasing the ash value several fold. Ash value is the general criterion to ascertain the purity of the drug. Total ash value of the drug was found to be 3.05%. Water insoluble ash mainly gives the percentage of organic matter present in the ash and this was found to be 2.23%. Acid insoluble ash, which mainly gives the percentage of the sand and impurities that remain insoluble in HCl and it was found to be 1.47%. Water soluble extracts of the drug mainly represents the percentage of organic constituents such as tannins, sugars, plant acids, mucilage and glycosides. Alcohol soluble extracts mainly represents the percentage of organic constituents such as alkaloids, phenols, flavanoids, steroids, sugars etc. present in the drug. Successive solvent extraction, which is the extraction of the drug with organic solvents of

AT

increasing polarity, was applied for the isolation of active constituents from the crude drug. The highest percentage of extract was obtained by the extraction with acetone (12.0 %) and least with the solvent cyclo-hexane 0.80 percent. The extracts obtained by exhausting crude drugs are indicative of approximate measure of their chemical constituents. Successive extraction showed scattered results because of the combination of two drugs. Due to Āmalakī cūrnam (Phyllanthus emblica) tannin present in all the extracts and steroids are present in all except cyclohexane extractive. While alkaloid (by Mayer‟s reagent) is present only in cyclohexane extract and alkaloid by Dragendroff‟s reagent present in all except water soluble extract. Phenol and flavonoids are present in all the extract except petroleum ether and cyclohexane extractives. Clinical study Student „t‟ test was applied to find out level of significance for all the parameters with in the treatment and control group. The data were statistically analyzed before and after intervention. Both the groups were not compared since only study group showed significant improvement on subjective parameters and only control group showed

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significant improvement on T3 and T4 level. None of them showed significant effect on TSH parameter. Probable Mode of Action in a nut shell It has been established for a very long time that there is a complex relationship between thyroid disease, body weight and metabolism. (K.P. Paulose, 2011). Thyroid hormones regulate metabolism in human. It is also reported that difference in BMRs are associated with changes in energy balance. (K.P. Paulose, 2011). Studies concluded that under secretion of thyroid hormones leads to low BMR and thereby weight gain, decrease in energy balance causes sleepiness and muscle cramps. Once the drug holds the body metabolism all these symptoms get relieved. Functions of thyroid hormone have a close resemblance to the Dhātvāgni (digestive potency of cells). (Alsa mariyam kalathancheri, 2008). Constipation is the foremost symptom of this disease which may be due to Agnimāndhya (loss of appetite) and Āma (indigested food material). Both the drugs are considered most excellent Pitta śamakas (drugs which mollify Pitta) and hence balance the Pitta and regularize the Dhātvāgni. Madhura (sweet) and Amlarasa (sore), Snigdha guna, Madhura Vipāka and Usna Vīrya (warmth in potency) of drugs simply mollify the aggravated Vāta. Kasāya rasa, Ruksa guna and Usna Vīrya eliminate the kapha in channels and also help in improving Agni. Once Agni get normalized, the signs and symptoms of Hypothyroidism like constipation, weight gain, excessive sleep and muscle cramp all get relieved. Guducī Satvam having Snigdha guna and Madhura rasa reduces the dryness of skin.

Āmalakī cūrnam by virtue of its Ruksa guna reduces the excess accumulated water in case of Hypothyroidism which is the main cause of weight gain. Study drugs, Guducī Satvam and Āmalakī cūrnam both having Rasāyana properties are best for longstanding disease like Hypothyroidism. In case of primary Hypothyroidism, the anomaly happens is in thyroid gland itself. The under-production of thyroid hormones leads to increased TSH from pituitary and various signs and symptoms. Considering rejuvenative property of drugs, their outcome can be justified. Being pitta śamana, they reduce inflammatory changes; being vāta śamana (drugs which mollify vāta) may reverse the condition of destroyed thyroid follicles or hold up the follicles to amplify the liberation of hormones. Anti-oxidant and immuno-modulatory effect of these drugs helps in this action. CONCLUSION HPTLC finger print showed more than four chemical constituents present in Guducī Satvam. HPTLC finger print showed 11 peaks may represent chemical constituents present in Āmalakī cūrnam. There is no negative impression in HPTLC profile of Thyromax powder due to combination of two herbs. Thyromax powder is found to be more effective in reducing the subjective parameters. Thyroxine sodium is found to be more effective on T3 and T4 parameters. Thyromax powder and Thyroxine sodium both are found to be insignificant on TSH level parameter.

REFERENCES Alsa mariyam kalathancheri (2008). Ayurvedic perspective on endocrinology with special reference to Hyperthyroidism and Hypothyroidism. Thesis submitted to Kerala University, Thiruvananthapuram.

Anonymous, Indian Council for Medical Research, New Delhi (2003). Appendix I and II, Quality Standards of Indian medicinal Plants. Vol. 1, 1st edition.235–37.

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Anonymous, The Controller of Publication (Reprint 2001), Appendix 1, 2.1, 2.2, 3 and 4, New Delhi. The Ayurvedic Pharmacopoeia of India. Part 1, Vol. II, 1st edition. 205–08. Anonymous. Pharmacopoeia of India (2001), Govt. of India, Ministry of Health. The The Controller of Publication. Vol.2; A – 53–55. Billore

KV, Yelne MB, Dennis TJ, Chaudhari BG (2005). Database on Medicinal Plants used in Ayurveda. Vol. 3, 1st edition. New Delhi, CCRAS,;11.

Chanchal Gupta (2003). A comparative study of Pipalī prayoga and Śodhan purvaka Śamana cikitsā in the management of dhātvāgni vikṛ ti (Hypothyroidism) Thesis Submitted to Gujarat Āyurveda University, Jamnagar. Dikshit V, Damre AS, Kulkarni KR (2003). Priliminary screening of immunocin for immunomodulatory activity. Indian J. Pharm Sci.71:254–7. Gay J Canaris, Neil R Manowitz, Gilbert Mayor, Chester Ridgway (2000). The Colorado Thyroid disease prevalence study. Arch. Intern Med.160:526–34. Source of Support: Nil

K.P. Paulose (Editorial) (July 2011). Kerala Medical Journal.; Issue4. N. Kochupillai, C S Pandav, MM Godbole, M Mehta and M M S Ahuja (1986). Iodine deficiency and neonatal hypothyroidism. Bill World Health organ. 64(4):547–51. Shukal V, Vashistha M, Singh SN (2009). Evaluation of Antioxidant profile and activity of Amalaki, Spirulina and wheat grass. Indian Journal of Biochem.24(1):70–75. Sir

Stanley Davidson (2006). Hypothyroidism. In: Davidson Principles & Practice of Medicine, 20th Edition, Churchill Livingstone Elsevier Health Science, Philadelphia, 691.

Unnikrishnan AG, Usha V Menon (2011). Thyroid disease in India- An epidemiological perspective. Indian J. Endocr Metab. 15:S78–81. Vanderpump MP (1995). The incidence of thyroid disorders in the community: A twenty year followup of the Whickham Survey. Clin Endocrinol (Oxf). 43(1):55–68.

Conflict of Interest: None Declared

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