The main aim of the study was to assess comparative clinical efficacy of 30 & 60 Puti Naga Bhasma with Nisha-Amalaki in patients of Madhumeha (Type 2 Diabetes) with honey as Anupana (adjuvant). Clinical study has obtained Institutional Ethics Committee clearance (PGT/7-A/Ethics/2016-2017/3968/2.9) and is registered at Clinical Trial Registry of India, ICMR, New Delhi, vide CTRI/2017/05/008451. The study was a randomized double blinded clinical trial. Computer generated Randomization method was used for generating randomization sequence. Patients of 30 to 60 years of age fulfilling inclusion criteria were selected and enrolled in the study irrespective of their sex, religion etc. from OPD and IPD of IPGT & RA, GAU, Jamnagar. Detailed history was taken and physical examination was done on the basis of a special proforma incorporating signs and symptoms of the disease.

Total 132 patients were registered in the clinical study taking into consideration of the inclusion and exclusion criteria and divided randomly in four groups. Double blind clinical trials study protocol was selected for trials. Blinding of three trial drugs was carried out prior to start the clinical study by third authorised person not included in study. Patients of fourth group were continued with their ongoing Tab. Metformin 500 mg prescribed by diabetologist as standard control witout any other additional intervention. Blinding was unrevealed after completion of the study, in fifth DRC (Departmental Review Committee) meeting in presence of all DRC members. Statistical analysis was done by using student t test, wilcoxson signed rank test and one-way annova test. At the end of statistical analysis blinding was unveiled. Group A (NAC) was identified as group treated with Nishamalaki Churna (125 mg) with placebo (roasted Sooji) 62.5 mg, Group B (NB60) was identified as group treated with 60 Puti Naga Bhasma (62.5 mg) with Nishamalaki Churna (125 mg) and Group C(NB30) was identified as group treated with 30 Puti Naga Bhasma (62.5 mg) with Nishamalaki Churna (125 mg) twice a day 30 min before meal with honey for 3 months. Patients of fourth group D (SC) were continued with their ongoing Tab. Metformin 500 mg prescribed by diabetologist as standard control drug BD before meal during afternoon and evening witout any other additional intervention. They were also advised to follow the dietary and other lifestyle mentioned in Ayurveda and modern literature for Madhumeha (Type 2 Diabetes mellitus). Effect of therapy was assessed based on relief in symptoms and investigations conducted FBS, PPBS, HbA1c and urine sugar before and after the treatment. Out of 132 patients 120 patients registered in total completed treatment while 12 patients discontinued treatment. 33 patients in each group were registered. Two patients of group A and one patient of group C showed incompatibility to come at regular intervals during treatment course. One patient of group A and Two patients of group D were left Jamnagar during the course of the treatment due to inevitable personal reasons. Two patients of group B and one patient of group D were refused for routine investigations at regular interval and discontinued treatment. One patient of group A and Two patients of group C were discontinued the treatment without any reason.

Majority of patients (58.33%) registered in trial belonged to age group of 51-60 yrs, and males (52.27%), while 96.21% were married. 41.67% of patients were housewives as female sex dominated trials, followed by 21.21% were labour/farmers. 55.30% of patients registered in trial had chronicity of 1-5 years followed by 26.51% having chronicity of 5-10 years.  Genetic predisposition was positive in 54.55% of registered patients. 20.45% of patients registered in trial had obesity as an associated illness followed by hypertension in 18.94% of patients. 90.91% of registered patients were following vegetarian diet. Irregular dietetary habits were observed in 37.12%.

Maximum no. of patients registered in trial had Madhyama Koshtha (56.06%), Madhura Rasa (81.82%), Guru (90.15%) and Snigdha Guna (65.91%) dominancy in diet. 26.52% of patients were having tobacco chewing as addiction. Disturbed sleep pattern was observed in 18.18% whereas 81.06% were having samyaka Nidra pattern. Work stress was observed to be present in 32.57% of patients. Variation in Prakriti pattern was noted in registered patients with maximum patients i.e. 31.06% were having Vata-pitta Prakriti, Madhyama Sara (64.39%), Madhyama Samhanan (72.73%) and Madhyama Pramana (71.21%). Lack of exercise was observed to be dominant (36.36%) in registered patients with Avara Jarana Shakti in 31.06% of patients. In Aharaja Nidana, Paya (milk) (75%) and Dadhi (79.54%) were noted as prominent causative factors along with Diwaswapa (Day Sleep) (80.30%) and Avyayama (Lack of exercise) (65.15%) as prominent life style related provocative factors for disease in registered patients.

Prabhuta Mutrata (Polyuria) as cardinal symptom was noted in maximum i.e. 90.90% of patients followed by Daurbalya (Generalised weakness) in 81.81% and Pindikodweshtana (cramps in legs) in 65.90% of patients. KaraPada Suptata (61.36%), KaraPadatala Daha (56.81%), Atisweda (56.06%) were observed in maximum no. of registered patients closely followed by Shrama in 53.03% of patients registered in trial.

In Dhatu Dushti, Meda Vriddhi was observed in 75.76% of registered patients followed by Rasa Vriddhi and Mamsa Vriddhi in 68.18% and 54.55% of patients respectively. Medovaha Srotodushti (97.73%) was observed in almost all registered patients followed by Udakavaha Srotodushti (89.39%), Rasavaha Srotodushti (87.88%) and Mutravaha Srotodushti (79.54%) respectively. Daurbalya as Upadrava was noted in maximum i.e. 81.81% followed by neuropathy in 61.36%, Trusha in 44.69% and skin changes in 15.15% of registered patients respectively.

Effect of therapy

In group A (Nishamalaki Churna), 33 patients were registered and 30 patients completed treatment with significant relief in symptom of Daurbalya (P<0.05) while in all other symptoms showed insignificant relief. In group B, 33 patients were registered and 30 completed the treatment. 60 Puti Naga Bhasma (62.5 mg) with Nishamalaki Churna (125 mg) is found highly significant (P<0.001) in symptoms pacifying like Prabhutmutrata, Avila Mutrata, Kara-Pada-tala Daha, Kara-Pada Suptata, Shrama, Pindikodweshtana and Daurbalya. While it is found significant (P<0.01) in symptoms like Mutramadhurya and Galatalu Shosha. In group C, 33 patients were registered and 30 completed the treatment. 30 Puti Naga Bhasma (62.5 mg) with Nishamalaki Churna (125 mg) is found highly significant (P<0.001) in symptoms pacifying like Prabhutmutrata, Kara-Pada-tala Daha, Kara-Pada Suptata, Atisweda, Shrama, Pindikodweshtana and Daurbalya. While it is found significant (P<0.01) in symptoms like Avila Mutrata and Galatalu Shosha. In group D, 33 patients were registered and 30 completed the treatment. Metformin (500 mg) is found significant (P<0.01) in symptoms pacifying like Prabhutmutrata, Atisweda, Shrama, Pindikodweshtana and Galatalu Shosha. While it is found insignificant in symptoms like Avila Mutrata, Mutramadhurya, Kara-Pada-tala Daha, Kara-Pada Suptata, Daurbalya.  

Effect on FBS: NB60 group & SC group showed statistically highly significant decrease (p<0.001) and NB30 showed statistically significant decrease (p<0.01) in FBS. While NAC group showed statistically insignificant (p>0.05) decrease in FBS. Percentage decrease in group NB60 observed was slightly more (17.01%) than group SC (13.22%).

Effect on PPBS: NB30 group & SC group showed statistically significant decrease (p<0.01) and NB60 showed statistically highly significant decrease (p<0.001) in PPBS. While NAC group showed statistically insignificant (p>0.05) decrease in PPBS.

Effect on HbA1c: NB60 showed statistically significant decrease (p<0.01) in HbA1c. While SC group showed statistically insignificant (p>0.05) decrease. NB30 group & NAC group showed statistically insignificant increase (p>0.05) in HbA1c.

Effect on Urine sugar: NB60 showed statistically significant decrease (p<0.01) in urine sugar. While all the other three groups showed statistically insignificant (p>0.05) decrease.

Effect on lipid profile: Statistically insignificant decrease (p>0.05) in serum cholesterol was observed in all the three groups while insignificant increase (p>0.05) was found in NB30 group. Statistically insignificant increase (p>0.05) in serum Triglycride was observed in all the three groups while insignificant decrease (p>0.05) was found in NB60 group. NB60 group & NB30 group showed statistically significant increase (p<0.01) while NAC showed statistically insignificant increase (p>0.05) and SC showed statistically insignificant decrease (p>0.05) in HDL.

Effect on renal profile: Statistically insignificant increase (p>0.05) in serum Creatinine was observed in all the three groups while insignificant decrease (p>0.05) was found in SC group. NB60 group & NAC groups showed statistically insignificant decrease (p<0.01) while NB30 and SC groups showed statistically insignificant increase (p>0.05) in serum uric acid. Statistically insignificant increase (p>0.05) in Blood urea was observed in all the four groups

Effect on liver function test: Statistically insignificant decrease (p>0.05) in total serum bilirubin was observed in all the three groups while insignificant increase (p>0.05) was found in NAC group. Statistically insignificant decrease (p>0.05) in direct serum bilirubin was observed was observed in NAC and SC group while insignificant increase (p>0.05) was found in NB30 group and statistically significant decrease (p<0.01) in NB60 group. Statistically insignificant increase (p>0.05) in SGOT was observed in all the three groups while insignificant decrease (p>0.05) was found in SC group. Statistically insignificant decrease (p>0.05) in SGPT was observed in all the three groups while insignificant increase (p>0.05) was found in NB60 group. Statistically insignificant decrease (p>0.05) in Alkaline Phosphatase was observed in all the three groups while insignificant increase (p>0.05) was found in NAC group. Statistically significant decrease (p>0.01) in total proteins was observed in all the three groups while insignificant decrease (p>0.05) was found in NB30 group. Statistically insignificant decrease (p>0.05) in Albumin was observed in all the three groups while insignificant increase (p>0.05) was found in NB30 group. Statistically highly significant decrease (p>0.001) in globulin was observed in NB60 and NB30 groups while significant decrease (p>0.01) was found in NAC group and insignificant decrease (p>0.05) was found in SC group.

Effect on haematocrit values: Statistically insignificant increase (p>0.05) in Hb was observed in all the three groups while significant decrease (p>0.01) was found in SC group. Statistically insignificant increase (p>0.05) in RBC was observed in NAC group while insignificant decrease (p>0.05) was found in NB60 and NB30 groups and statistically significant (p>0.01) was observed in SC group. Statistically insignificant increase (p>0.05) in WBC was observed in NAC and NB30 groups while insignificant decrease (p>0.05) was noted in NB60 and SC groups. Statistically insignificant increase (p>0.05) in Neutrophils was observed in NAC and SC groups while insignificant decrease (p>0.05) was found in NB60 and NB30 groups. Statistically insignificant decrease (p>0.05) in Lymphocytes was observed in all the three groups while insignificant increase (p>0.05) was found in NB60 group. Statistically insignificant decrease (p>0.05) in eosinophils was observed in NAC and NB60 groups while insignificant increase (p>0.05) was found in NB30 and SC groups. Statistically insignificant decrease (p>0.05) in monocytes was observed in all the three groups while insignificant increase (p>0.05) was found in NAC group. Statistically insignificant decrease (p>0.05) in ESR was observed in all the NAC and NB30 groups while insignificant increase (p>0.05) was found in NB60 and SC groups. Statistically insignificant decrease (p>0.05) in platelet was noted in all the three groups while insignificant increase (p>0.05) was found in NAC group.

Overall effect of therapy:

Improvement in all signs and symptoms of Madhumeha was analyzed, while evaluating the overall effect of therapy. Assessment of overall effect of therapy was done through the gradation. The results obtained during the study in the signs and symptoms were assessed and analyzed statistically before and after treatment.

Comparison between overall effects of therapy of four groups

In group NAC out of 30 completed patients among them 40% were unimproved, 30.00% were mildly improved, 26.67% were moderately improved and 3.33% of patients showed marked improvement at the end of treatment period. In group NB60 out of 30 completed patients among them 3.33% were unimproved, 13.33% were mildly improved, 60.00% were moderately improved and 23.33% of patients showed marked response after completion of treatment period. In group NB30 out of 30 completed patients among them 6.67% were unimproved, 20% were mildly improved, 56.67% were moderately improved and 16.67% of patients showed marked response after completion of treatment period. In SC group out of 30 completed patients among them 6.67% were unimproved, 40% were mildly improved, 43.33% were moderately improved and 10% of patients showed marked response after completion of treatment period. Relapses were insignificant during the follow-up period. Comparative relief in all the four groups was evaluated by one way annova test. Effect of the therapy was demarcated as percentage wise group B is more effective in compare to Group A, Group C and Group D.

Adverse drug reaction:

A drug can be panacea or poison. A drug fulfilling the criterion of a standard drug will always become panacea provided, if it is used properly. On the other hand, a poorly prepared or manufactured drug however used skillfully, will always prove to be a poison. Acharya were perceptive of all the probable adverse effects if Naga is administered in impure form or without appropriate processing such as Shodhana (purification), Jarana (roasting) and Marana (incineration). For this especially patient safety evaluation proforma was prepared and monitored for all the probable Adverse drug reaction. No undesirable effects were observed in patients during and after the clinical trials.

No drug to drug interactions were observed during the trial period shows safety aspect of the trial drug. All the trial drugs showed compatibility with contemporary medications such as metformin, glipizide etc. during the trial period.

No any significant derangement in haematological and bio chemical parameters was noted in all the groups which shows safety of all the 3 formulations.

Determination of lead and arsenic in blood serum was performed by inductively coupled plasma atomic emission spectrometry (ICP-AES) at SAIF, IIT Bombay, Mumbai. Lead and arsenic were not detected in before and after treatment serum samples of 40 patients of NB30 and NB60 Groups.

Microscopic examination showed absence of basophilic stippling, RBCs were normal in shape and size. Hemoglobin and Red blood cells were within the normal limit in all treated three groups. There were also no any symptoms found of hemolytic anemia.