Correspondence

Ayurveda for diabetes in

India
We believe that Anoop Misra and
colleagues depiction of Ayurvedic
medicine in their Correspondence
(April, 2016)1 on alternative medicines
for diabetes in India contains several
inaccuracies.
The causes, pathogenesis, and
disease management of diabetes
have been well established in
Ayurvedic medicine. Ayurveda disease
management entails a prescription of
personalised diet, lifestyle, medicines,
and systemic cleansing therapies. Each
treatment plan is customised to the
individual patient and to the type and
stage of diabetes.
Regarding the scarcity of studies of
Ayurvedic treatments mentioned by
Misra and colleagues, it is important
to keep in mind that classic Ayurvedic
medicines are usually polyherbal
formulations. The combined effect
of the phytochemical constituents
of various herbs is responsible
for therapeutic efficacy, rather
than the actions of a single active
ingredient.2 Thus, standard doubleblind randomised controlled trials
are not frequently used for Ayurvedic
treatments because the multi-faceted
approach to diabetes management is
not amenable to trials that examine a
single component of an individualised
treatment plan. Research methods
in studies of Ayurveda are based
on a black-box designie, given as
they would be in the usual clinical
environment.
Misra and colleagues associate
alternative medicines for diabetes
with so-called nutraceuticals. It
is important to note that Ayurveda
medicines (which predominantly
consist of herbal content) are
often erroneously regarded as
nutraceuticals, which they are not,
notwithstanding the fact that many
studies have shown the efficacy of
nutraceutical products across various
uses.3 The authors assertion that there
is indistinct compartmentalisation
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between functional foods, herbs, and

Ayurvedic medicines is inaccurate; the
Indian Government has published the
Ayurvedic Pharmacopeia of India, which
clearly defines what an Ayurvedic
medicine is.4 Furthermore, it is not
clear on what basis the authors claim
that Indian guidelines have waived
or relaxed the rules for rigorous
pharmacological and toxicology
studies for Ayurvedic products. The
Indian Government has in fact dened
guidelines for Ayurvedic drugs.5
The authors allude to heavy metal
toxicity in Ayurvedic preparations
sold on US websites. The Indian
Government has reiterated that
Ayurvedic medicines should not be
purchased over the internet. 6 Lax
market regulation should not be
used to malign a time-tested medical
system. A scheme of voluntary
accreditation for quality and safety,
the AYUSH mark, has been introduced
and numerous traditional medicines
have been assigned this label. There
are also laws and regulations that
apply to the manufacture and sale of
Ayurvedic pharmaceuticals.
Although scientific endeavour to
establish the safety and efficacy of
Ayurvedic treatments through robust
research protocols is an ongoing
priority, there is an insucient basis
on which to reject Ayurveda in its
entirety, as suggested by Misra and
colleagues. We believe the authors
have an incomplete understanding
of the Ayurvedic method of disease
management, and welcome a
constructive dialogue with researchers
and clinicians who are interested in
gaining deeper insights into Ayurveda.
We declare no competing interests.

*Rajiv Vasudevan, Zankhana Buch

rajiv_vasudevan@ayurvaid.com
AyurVAID Hospitals, 9th Cross, JP Nagar Phase 2,
Bangalore 560076, India
1

Misra A, Gulati S, Luthra A. Alternative

medicines for diabetes in India: maximum hype,
minimum science. Lancet Diabetes Endocrinol
2016; 4: 30203.
Parasuraman S, Thing GS, Dhanaraj SA.
Polyherbal formulation: concept of Ayurveda.
Pharmacogn Rev 2014; 8: 7380.

Leung L, Birtwhistle R, Kotecha J, Hannah S,

Cuthbertson S. Anti-diabetic and
hypoglycaemic eects of Momordica charantia
(bitter melon): a mini review. Br J Nutr 2009;
102: 170308.
Ministry of Health & Family Welfare,
Government of India. Pharmacopoeial
laboratory for Indian medicine. http://www.
plimism.nic.in/publications.html (accessed
Aug 17, 2016).
Central Drugs Standard Control Organization.
Traditional drugs guidelines. Sept 24, 2014.
http://www.cdsco.nic.in/forms/list.
aspx?lid=1856&Id=1 (accessed Aug 17, 2016).
Ministry of AYUSH. Public Notice to consumers
and stakeholders for promoting safe use of
ASU Drugs. http://ayush.gov.in/acts-rulesand-notications/public-notice-consumersand-stakeholders-promoting-safe-use-asudrugs (accessed Sept 22, 2016).

Authors reply
We thank Rajiv Vasudevan and
Zankhana Buch for their interest in
our Correspondence1 on alternative
medicines for diabetes in India. The
authors suggest that the pathogenesis
of diabetes and disease management
have been well characterised in
Ayurvedic medicine without providing
any references. This omission is
important, because whether such
characterisation of diabetes and its
treatment in Ayurveda is based on
ancient treatises written by individuals
thousands of years ago, or on
principles of modern science, is the
central issue.
Vasudevan and Buch attempt to
argue that the use of polyherbal
preparations in Ayurveda prevents the
application of scientific assessment.
But this situation is exactly what is in
need of improvement. Specifically,
each component of these polyherbal
preparations rst needs to be puried
and then scientifically tested for
efficacy. Those components that
are efficacious alone and show
enhanced efficacy in combination
with another component (synergistic
effect) can then be combined in a
single formulation. These are simple
principles of drug development
worldwide and should also be applied
to Ayurvedic treatments.2 Notably,
the paper3 on polyherbal formulation
in Ayurveda cited by the authors
contains statements to the eect that

www.thelancet.com/diabetes-endocrinology Vol 4 November 2016

Correspondence

polyherbals are not safe, that toxic

heavy metals are added for better
ecacy, and that the regulations for
Ayurvedic herbal preparations are
less stringent than for other drugs, in
agreement with the content of our
original Correspondence.
The authors also state that many
studies have shown the efficacy of
nutraceutical products, for which
they refer to a single reference, a
mini review4 of the anti-diabetic and
hypoglycaemic eects of Momordica
charantia (bitter melon). Later, the
authors cite a website that lists several
Ayurvedic pharmacopeias. Because we
do not have access to the full texts of
these pharmacopeias, it is unclear how
these publications might have dened
functional foods, herbs, and Ayurvedic
drugs to prevent overlap in these
categories. The fifth reference cited
by the authors is for a website that
states denitions of Ayurveda, Sidha,
and Unani drugs, and does not contain
guidelines as suggested by Vasudevan
and Buch. We are happy to note that
the authors accept that Ayurvedic
drugs might be toxic and should not
be sold over the internet. But in India,
these drugs are sold over the counter
in shops that sell allopathic and
alternative medicines, and frequently
by unqualied people on the roadside.
Recent published statements lend
support to what we stated in our
Correspondence. First, in a recent
statement,2 the Indian Council of
Medical Research (Ministry of Health,
Government of India) noted: Though
traditional systems of medicine
(termed complementary and alternate
systems in the west) are known for
their long history of safe and eective
use, validation of safety and ecacy
using scientific and evidence-based
methodologies is needed for the
purpose of universal acceptability,
gaining confidence of practitioners
and satisfaction of end users in the
products. Second, a statement5 from
the website of the National Center
for Complementary and Integrative
Health (US National Institutes of

Health) notes that not only might

Ayurvedic medicines be harmful,
but that there arent enough wellcontrolled clinical trials and systematic
research reviewsthe gold standard
for Western medical researchto prove
that the approaches are beneficial.
Finally, we agree with the authors that
we have an incomplete understanding
of Ayurveda, which is simply because
of the paucity of clear, scientic data,
and due to poorly done studies that are
often not based on modern principles
of drug trials.
We declare no competing interests.

*Anoop Misra, Seema Gulati,

Atul Luthra
anoopmisra@gmail.com
Fortis C-DOC Center of Excellence for Diabetes,
Metabolic Diseases, and Endocrinology, New Delhi,
India (AM); Diabetes Foundation (India), New Delhi,
India (AM, SG); and National Diabetes, Obesity, and
Cholesterol Foundation, New Delhi, India (AM, SG);
and Fortis C-DOC, Fortis Memorial Research
Institute, Gurgaon, India (AL)
1

Misra A, Gulati S, Luthra A. Alternative

medicines for diabetes in India: maximum hype,
minimum science. Lancet Diabetes Endocrinol
2016; 4: 30203.
Sharma NC. Medical research body calls for
Ayurveda drug litmus test. http://www.
dailymail.co.uk/indiahome/indianews/
article-3715197/Medical-research-body-callsayurveda-drug-litmus-test-increasecondence-use.html (accessed July 29, 2016).
Parasuraman S, Thing GS, Dhanaraj SA.
Polyherbal formulation: concept of Ayurveda.
Pharmacogn Rev 2014; 8: 7380.
Leung L, Birtwhistle R, Kotecha J, Hannah S,
Cuthbertson S. Anti-diabetic and
hypoglycaemic eects of Momordica charantia
(bitter melon): a mini review. Br J Nutr 2009;
102: 170308.
National Center for Complementary and
Integrative Health. Ayurvedic medicine: in
depth. https://nccih.nih.gov/health/ayurveda/
introduction.htm (accessed July 29, 2016).

Adrenal vein sampling

versus CT scanning in
primary aldosteronism
We read with great interest the
SPARTACUS study,1 which showed that
the use of either adrenal CT scanning
or adrenal vein sampling (AVS) to
differentiate unilateral aldosteroneproducing adenoma from bilateral

www.thelancet.com/diabetes-endocrinology Vol 4 November 2016

adrenal hyperplasia led to similar blood

pressure improvement in patients
with primary hyperaldosteronism.
AVS is the current gold standard
for subtyping patients, but criteria
vary between centres. Although a
lateralisation ratio of more than
4:1 identifies unilateral disease,
patients with lower ratios might
also have clinical improvement
after adrenalectomy.2 Contralateral
suppression, useful in predicting
response after surgery,3 might help
improve subtyping.
These results revisit the perception
that aldosterone-producing adenoma
and bilateral adrenal hyperplasia might
be a continuum. The current criteria for
pathological diagnosis of aldosteroneproducing adenoma are far from
definitive. Adrenal glands removed
because of unilateral disease have
shown nodular hyperplasia instead of
a single nodule with surrounding zona
glomerulosa hypertrophy.4 Somatic
mutations were found in 50% of
these adrenal glands.5 Could there be
similar occurrence of hyperplasia on
the contralateral side to explain the
persistent hyperaldosteronism one
year after adrenalectomy in some
patients in this study?
Finally, 37 (39%) of 950 patients
in a meta-analysis showed unilateral
hypersecretion by AVS that was on the
contralateral side of the adrenal nodule.2
We found that two (6%) of 31 patients
with successful bilateral cannulation
on AVS had unilateral hypersecretion
on the side contralateral to the nodule
(unpublished). This might explain why
the CT-based approach resulted in
more patients with persistent primary
aldosteronism than AVS (nine patients
vs ve patients), although SPARTACUS
was not adequately powered to conrm
this difference. Conversely, patients
with bilateral normal or abnormal
adrenal glands on CT might have
unilateral hypersecretion on AVS;
these patients might not benet from
surgery. We counsel caution before
dispensing with AVS, but keep watch
for a paradigm shift.

This online publication has

been corrected.
The corrected version rst
appeared at thelancet.com/
diabetes-endocrinology on
November 22, 2016

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