Homoeopathic Medicines As Supportive Therapy For Managing Severe Haemophilia Patients In A Resource Constrained Set Up Of A Developing Country.
Haemophilia is a genetic bleeding disorder resulting from deficiency of clotting factor VIII (Haemophilia A) or Factor IX (Haemophilia B). The disease affects males where as females are the carrier. A person with Haemophilia (PWH) suffers various bleeding episodes ranging from superficial cuts and bleeds to life threatening intra cranial hemorrhage whereas haemarthrosis remain the common presentation of the disease. Latest Haemophilia census says that there are all together 60-70,000 haemophilia patients are there in the country of which 90% suffers from Haemophilia-A, remaining 10% of Haemophilia B. Only 16,000 are registered in National Haemophilia Register. Remaining patients are undetected due to poor awareness and paucity of latest updated Investigations as available in IHTC only.
Common problems of PWH
Haemarthrosis is the commonest presentation, and can occur 2-3 times/weak. The repeated bleeding in the joints leads to joint deformity thereby increasing the morbidity. Conventional management of the disease includes infusion of deficient factor concentrate/FFP during bleeding phase and physiotherapy is recommended to increase the joint mobility. Repeated infusion with factor concentrate or FFP carry the risk of transmission of transfusion related disorders like Hepatitis C,HIV etc .and may develop Factor inhibitor. A PWH with inhibitor requires to be infused with FEIBA (Factor Eight Inhibitor Bypass Activity). In developing country like India where 80% of population resides in rural areas and more than 80% of PWH belong to lower socio- economic strata having per capita income between 15,000-40,000/year, the exorbitant cost of the standard hemophilia management makes it out of reach of many haemophiliacs. The treatment cost increases in patients with inhibitor positive/ Hepatitis C infection or if there is any associated disease.
Inception of the project:
In view of above a charitable research project has begun in 2007 by Dr. Tapas K Kundu, at Nashik with all necessary Advises, Navigation and Support from Dr. Kanjaksha Ghosh. All Laboratory investigations were carried by in NIIH and IHTC. Hemophilia Federation of India played very important role by providing patients in all centres from the respective chapters and by extending logistic support (in Mumbai and Surat). Homoeopathic medicines are being given as a supportive management during bleeding and non-bleeding phase with the following objectives.
- To minimize the bleeding episodes of PWH without compromising with the quality of life.
- To increase the adaptability of PWH.
- To reduce morbidity.
During acute bleeding episodes homoeopathic medicines based on the law of similia (TOS) are prescribed along with the use of Hammamelis Q as a local application (cold fomentation). In case of haematuria, where factor infusions are generally avoided, the same is given orally dissolved in water. Patients are asked to maintain a diary noting the number of bleeds, amount of factor utilized , daily activities , any psychological upsets or altered behavior. A detailed case report format is filled and a constitutional similimum is prescribed based on symptoms pertaining to emotions/psychology in response to the disease(Cognitive symptoms- obtained from interaction with the patients and gist from the diary), behavioral changes adopted to cope with the disease( Conation) along with characteristic physical and particular symptoms. The repetition of the doses is done according to the susceptibility. The disease is managed as per the severity under three levels.
Level I: Advocated For Patients As Self Management
- Soak a gauz piece with hammamelis q 10-15 drops
- Apply over the affected part q +1 cup water for 15-20 min
Level II: frequently used medicines with indication (Acute Prescription)
- Calcarea Carb 1M- Muscle haematoma with ecchymosis.
- Bryonia Alba 30- Painful swelling of the joints ameliorated by rest.
- Apis Mellifica 30/6- Swelling of joints with effusion and redness of overlying skin.
- Ledum Pal 30- Pain/swelling of the joints ameliorated by cold fomentation.
- Arsenic Album 6/30- Restlessness with pains and amelioration by warmth.
- Lachesis 6/30- Increased activity of children inspite of injury or pains. Bleeding dark in color.
- Phosphorus 30-Bright red bleeding with anxiety.
- Rhustox 30-A/f over exertion of the muscles. Amelioration by continuous motion.
- Silicea 30/200/1M-Sense of responsibility despite the sufferings. H/o-repeated factor/cryo ppt/plasma infusion.
- Merc Sol 200/1M- Individuals reacting violently with pains associated with intense thirst and flabby tongue.
Level III: Selection Of Constitutional Similimum Based On
1.Persistant behaviour of the patient obtained from
- The Daily Dairy
- Physician’s Observation
- School teachers’ report or peer report.
- History obtained from the case performa
- Emotional/psychological symptoms
- Physical Generals
- Miasmatic Diagnosis
*** In all three levels the medicine is selected as per the law of Similia and also the unified decision of the treating physicians (at least two) and where Fleiss kappa is substantial.
Evaluation of the patients: Besides noting the number of bleeds, patients are evaluated as per the following scales by the physicians.
- Pain Rating Scales: a.Wong Baker Pain rating scale(0-10) for children below 10 years
- Numerical pain rating scale(0-10) for individuals 10 0r above
2.Vineland’s Adaptive Mal adaptive behavioral scale (0-24) (Modified-2007)
- Activity (0-8)
- Co-operation (0-8)
- Communication Skill (0-8)
- SF-32 joint mobility scale.
- Pain Type
- Swelling (Measured In Cm)
- Range Of Motion
4.Frequency of bleeds:
- Number of bleed
- Duration of bleed
- Healing time
- Factor required/not/amount of factor required.
Service To PWH:
To start with 14 PWH were enrolled during first camp at Nashik, which slowly went on increasing and till date we have treating total no of 806 patients in our three nodal centres and three sub centres (Table 1). The PWH from various parts of Maharashtra and India are being treated under Nashik Centre. Extending the service to other parts of Maharashtra and Gujrat, haemophilia centres such as Mumbai, Surat , Miraj and Amrawati has started with 313,81,46, 42 patients respectively.
|Updated till 30-04-2015||Nasik||Mumbai||Surat||Miraj||Amrawati|
|Total number of Camps Conducted||89||87||49||30||16||2|
|Emergency & telephonic prescribed||3,047||429||337||255||54||6|
|Total number of interactions with patients||11,141||1798||486||281||234||73|
|No. of patients||324||232||81||81||46||42|
During monthly camps along with homoeopathic medicines, physiotherapy and psychological counseling are also provided.
All emergencies are attended by the corresponding centres as they belong to.
- As an outcome of the study the research paper saw the light of publication under the
ELSEVIER-Homoeopathy entitled ,” Homoeopathic medicines substantially reduce the need of clotting factor concentrate in haemophilia patients: results of blinded placebo controlled cross over trial. Homeopathy (2012) 101, 38-43, 2011.
2.The homoeopathic medicines are found to reduce the episodes of bleeding as well as effective in the management of acute bleeding episodes whether concealed ( Haemarthrosis, intra muscular bleeds especially psoas bleed) or open ( epistaxis, bleeding from injury, fall of teeth, conjunctival or haematuria). The analysis of this study is under the process of publication.
Social Impact Of The Project;
- The prevalence of PWH of factor inhibitor ranges from 8.2-13%.This percentage is observed to reduce to a great extent as only 1% of haemophiliacs under homoeopathic treatment were found to be positive for Inhibitor.
- With homoeopathic medicines as a supportive therapy the cost of the disease management greatly reduced. Savings on Individual patient’s average usage at a rate of Rs 10/IU on (12347-864 ) e. 11383 Iu X 10 = Rs. 1,13,830 /patient/ year.
Cost of homeopathic medicine including doctors fee will not be more than Rs. 4000/ year. Hence final overall financial gain with better health status as they bleed less often is Rs 1,09,830/ pt/ year.
- Carrier Mother Project:
Genetic counseling is the main tool for the prevention and control of the disease, targeted at families with affected birth or with a family history of disorder. A project for carrier mother is started with the view to limit the transmission of faulty gene to the offspring. The success of this project might reduce the incidence of haemophilia. The females planning to conceive are given Homoeopathic similimum and is repeated in infrequent interval during pregnancy.
- Patients with Hepatitis C Haemophiliacs developing Hepatitis .C infection as a consequence of repeated factor infusion are also being treated.
- Patients with Inhibitor: Patients diagnosed as FVIII Inhibitor positive are also being managed with homoeopathic medicine.
- Counseling: Most of the females experience marital conflict on account of being carrier of the disease. These conflicts are taken care by psychological counseling with the parents and family members. Carrier young girls prefer to stay unmarried to avoid problems in future. These females are motivated to take up positive decisions in life.
Funding For The Project:
The project is being run for past seven years on charitable basis. The medicine and other logistic support are managed by the project co-coordinator and Investigators.
Pople Behind The Project
Prof (Dr.) Tapas Kumar Kundu
BHMS (Cal), PGDPC, MS(Ibms)
Co-Investigators: Dr. Afroz Farooque Shaikh, Dr. Priyanka D. Singh,Dr. Aafiya Sheikh, Dr. Hiral Shah Bothra, Dr. Omkar R. Kumat
Courtesy : The paper orginally presented in world homoeopathy submit at Mumbai by Global Homoeopathy Foundation (GHF)