Namaste everyone, welcome to another Ayurvedic case management podcast through Athreya Herbs.

We are here to support our community of Ayurvedic practitioners with cases that we manage through Ayurvedic discussion and where we want to increase our critical thinking ability and become better practitioners. We have Dario who has been very generous in bringing his cases to discuss with us. He is a seasoned Ashtanga Yogi, he practices in Tijuana, Mexico. He’s been seeing patients and he has graduated as an Ayurvedic practitioner from an American University of complementary medicine. He has some wonderful cases, one of the cases that we had was him taking the PanchaKarma and how it can be a little bit harsh on us if we don’t know what we are doing. This case is interesting and I welcome Dario to present his case so we can discuss what are the protocols we wanna do or what kind of a diet we want to do or the kind of yoga or breathing that we want to do or what kind of diet we want to follow.

Vaidya- Welcome Dario again to the Athreya herbs practitioner podcast

Dario- Namastey Vaidya Jay. Thank you for inviting me.

Vaidya- It’s our pleasure and I know that you have been seeing a lot of cases in your practice so I cannot wait to see what interesting case we have today. What we’re going to do is usual, we’ll chant and invite Lord Dhanvantari and listen to your case.
Thank you very much.

Dario- I had a person who came to see me - male, 55 years of age, his Constitution is Pitta and Kapha and he comes to me because he wants to lower his cholesterol level, which is high but I do not think it is very high, it is 214 total cholesterol. He also had a little bit of an issue urinating, he mentioned it was a little weak but he wasn’t too concerned about it he was more concerned about his cholesterol. There is some family heart history and he is under the supervision of a doctor. They want to make sure that he is controlling his cholesterol and he doesn’t want to take any medications so he came to see me. I took his pulse and it was a bit weak and superficial. I noticed that his gallbladder pulse was a little bit weak too. He was a little bit overweight and still is a little bit overweight so I decided to start the protocol with a green smoothie and add 1 tablespoon of fenugreek seeds to his breakfast for a month. I also recommended a cup of hot water with honey and a little bit of lemon to drink early in the morning. I gave him a little bit of Trikatu to increase his Agni and Triphala Guggulu to help and lower the cholesterol. I recommended two capsules 2-2-2 after each meal for two weeks and then after that one after each meal 1-1-1. To help him with urination I also recommended 1 capsule of Shilajit in the morning after breakfast. The first time I saw him I checked out his tongue and it was covered with a whitish coating or Ama so after the month of following the protocols with the smoothie and the capsules his tongue was clean. It looked like we were on the right track. I suggested that he continue with the smoothie and Triphala Guggulu for another month. I increased the dosage of Shilajit to 1-1-0 and added some Guduchi to help with his immunity and to maintain his Agni. I started him with 2-2-2 for a week and eventually came down to 1-1-1 afterward so that was his protocol for another month. When I saw him at the beginning of the third month I took his pulse, it was very superficially light and almost very difficult to perceive. I asked him to show me his tongue, and it still had a coating, this time it was a bit yellowish but it was further on the back of the tongue. I should also mention that I noticed in the beginning that he has a very deep groove in the middle of the tongue. It was surprising for me as I did not expect his tongue to still be covered especially after having the smoothie for 2 months. So I asked him if he was going to continue with his diet which was no dairy, no oily food, no flour. He said the first month was fine, the second month was like 80%. He mentions that he loves potato chips so he was diving off and on in these potato chips, I told him he needed to hang on for another month but control the diet for us to lose some of that cholesterol or Ama. I was trying to change the strategy now so I changed his medication from Triphala Guggulu to Kanchanar Guggulu to keep cleansing and to move his Divya Dhatu and I also asked him to take 1 teaspoon of Haritaki after breakfast and dinner. About three days later he went in for another blood test and in the beginning, the blood test that he showed me seemed fine except for the high cholesterol, triglycerides were a little bit high as well but this time when he took another blood test his cholesterol did go down from 214 to 184 and the triglycerides went from 199 to 164. His good cholesterol, in the beginning, was 38 which should be around 40 or greater than 40 but it went down to 31. Then the LDL, in the beginning, was 165 and it went to 144. It seemed okay except for one thing on the first test nothing came out on the liver, but this time the AST went to 62 whereas, in the beginning, it was17, ALT, in the beginning, was 22, and then later it went up to 151 so he was concerned and I was concerned too about what could’ve happened. He is afraid now of taking any herb, he thinks that it was the herbs that congested his liver and I suspect that he went really well for a whole month, cleaned his diet, and then started bingeing on junk food, not every day but sporadically. This is my theory on how we may have congested his liver and gallbladder.

Vaidya- This is a very interesting case. Let’s get into a little more detail of this case so you were doing this smoothie for two months, were you doing Trikatu and Triphala for 2 months or did you stop both of them at some point?

Dario- I stopped with Trikatu after a month and Triphala I kept for the second month.

Vaidya- How much of the Triphala were you giving Dario?

Dario- Triphala Guggulu was 2-2-2 for 2 weeks afterward it was 1-1-1.

Vaidya- So you did not do Triphala?

Dario- No, I didn’t just Triphala Guggulu.

Vaidya- So this person is Pitta- Kapha Prakriti, 55 Years old so the interesting part is that your selection of things for him – diet was perfect, the diet of not consuming anything that increases Kapha and Ama, Agni dampening or anything that slows down the Agni you tried to cut down. Your recommendation of no cheese, no heavy foods was perfect. In terms of herbal choices was there an issue with his appetite when he came to visit you and was he sleeping okay?

Dario- No his appetite was okay and his sleeping was 80%.

Vaidya- He sometimes had this urinary difficulty. Sometimes he used to have a low stream. So what happened is your herb choices - Triphala Guggulu in the first month, Kanchanar Guggulu in the second month, the smoothie with dandelions and fenugreek, morning hot water with honey and lemon and he also took some Shilajit and Guduchi so all these Dravyas and things that you did are Pitta Saraka which means they increase the Pitta to flow. Pitta is in the Pachaka Agni or the digestive system or Ranjaka Pitta that is in the liver because the bitter dandelions are also liver activating, Fenugreek mainly works on the Medha Dhatu and Rasa Dhatu as well as Koshta or gut. That also is a slight ‘Sara’, before that I want all our listeners and practitioners to pay attention to is Sara Quality. So Sara is the liquid or a flowing quality, what you do is by encouraging Sara quality you mobilize all the fat that wasn’t moving properly and then the Triphala Guggulu that is also capable of breaking down the Ama and Kapha and eliminating it. You did do all of that to help the stagnant Medha Dhatu to become dissipated and move along. You also choose the right organ as the liver is the main organ that stores cholesterol. Being given all of this the cholesterol and Ama started dissipating and you did Ama Pachana to some extent. The Ama Pachana started happening and then simultaneously you were doing Pitta Saraka(Pitta secreting action) Dravyas which was wonderful. So the first time he came everything was getting better - you checked the tongue was clean in a month and everything seemed to be working well, it seemed he was following all the instructions. He goes back so what happens is in this one month you mobilize all the Pitta Dosha which is his primary Dosha as well. It all mobilized, you brought it from all the Shakas, Dhatus, etc to come to the Koshta but among all of this you never had anything to purge, you did not do any Rechana, Ramsana, or Anulomana. You continued to work and you also increased a little bit of Shilajit so all of that again increased the quantity of Pitta, And it does not know where to go now so it’s all in the gut or Koshta. The Pitta that is not eliminated continue to stay in the gut and then maybe he started changing his diet because he was feeling a little better but internally what happened was that all the Mala that is Malarupi Pitta or waste product Pitta or Pitta that isn’t healthy was generated from the Ranjaka Pitta in the liver, Gallbladder, stomach-where ever it was generated all of that started to get reabsorbed. When he came back and you looked at his tongue you were confused about what happened since you never created an outlet for that Pitta to move out. That is why I asked you that question about using Triphala too instead of just Triphala Guggulu. You need to purge Pitta because Pitta, Kapha, Ama all have the Snigdha quality. What happened to the cholesterol that was there from the Kapha type of cholesterol it turned into Pitta type of cholesterol so it took all the Pitta qualities. As a result, you would see that ALT and AST (Aspartate transaminase) that is the liver enzyme started going up. What you should have done was tell him- hey it’s okay I’ll give you something to purge. You could have done a little purge for him even taking a large quantity of Triphala every night for about five days or one week would have purged all the Pitta out.

Dario- Where do we purge the pitta out from the gut, or liver, or gallbladder?

Vaidya- From the gut or Koshta, the liver is a part of Koshta. Once you start purging the Koshta everything is drawn or purged out.

Dario –why isn’t Triphala Guggulu doing that?

Vaidya- Triphala Guggulu is not a Saramsana or a purger, it reduces or scrapes the Ama but doesn’t eliminate it because Triphala Guggulu has Triphala, Guggulu, Pippali, and Guduchi. None of these when they combine together will be able to act as purging agents. You may believe that there is Triphala but its action when you combine it with Guggulu becomes scraping rather than purging and it did what it’s supposed to do, it scraped out all the triglycerides, cholesterol and everything came down. The thing is what all is mobilized is called the Malarupi Pitta because you’re increasing the Pitta, Trikatu, Triphala Guggulu is there and you did dandelions, some amount of Shilajit so all the Pitta that is generated has to go somewhere and it came to the Koshta. In the second visit or the follow up when you saw the clean tongue, you should’ve done one purge. That is why you see in the classical textbooks Ayurveda explains that whenever the Doshas are in Vilayana. Vilayana means you made them liquefied or loose, if you do not eliminate them they go right back into their spaces. What I would’ve done for this patient the second time he came to visit me – I would have suggested six capsules of Triphala once every three days for 3 weeks, some hot water and then you can expect 4 to 5 purges. During the day – eat light, drink lots of hot water and they should be fine. This would have been a wonderful approach for this case and he would have purged out about 7 times.

Dario- Can it also be powder?

Vaidya- Yes it can be a powder or you can even do Avipattikar or Triphala powder. If you want to do the powder, it is 1 1/2 teaspoons of Triphala in the morning with hot water. Your choices were correct but when the Doshas came into the Koshtas from the Shakas there was no outlet for that so they went back to their respective places, imagine the Pitta that you have stimulated to digest that Ama stayed in the liver – in the Ranjaka Pitta level, but it’s still not too late if he is willing you can recommend a detox – Triphala powder or capsules in the same quantity as I mentioned and then observe. You can ask him to go in for another liver test maybe after two or 2 1/2 months and you can see these numbers become normal. After the three weeks, you will stay on to the program that you are doing right now since Guduchi is great. Was the urinary function better after the recommendation of Shilajit?

Dario- Yes, He said it was better.

Vaidya- Go back to Shilajit that’s fine and make sure that you are also giving him something during the day to have a bit of an Anulomana effect. What I would do is instead of recommending Triphala at that higher dose I would reduce it to 2 capsules in the morning and the night during the week. The day when he is not purging after the three weeks purge continues with Triphala pills in the morning and the night. The powder you can do half a teaspoon in the morning and the night as well. He can continue taking that and he will purge out all the Pitta Little by little.

Dario – Will he have loose stool?

Vaidya- Yes, slightly loose but not bad. You can inform him that he would have one or two bowel movements during the day. I think doing that will immediately start purging the stagnant Pitta out and you can continue with the green smoothie since that is not a problem because the green smoothie is mobilizing the stagnant Pitta- you have Ama Pachakas which are bitter and some of them are astringent in taste, turmeric, ginger will mobilize the Pitta, You only have to create an outlet.

Dario – You chose Triphala but what about using Amalaki?

Vaidya- Amalaki by itself is not a purging agent. You want to do Shamana or Shodna, Shamana means to pacify- you cannot pacify because there is so much of Dosha you need to purge it out, that is you need to do Shodna. It means the Pitta that is aggravated with Ama, you cannot pacify it by using Amalaki. You need to use Triphala to purge it out or do Rechana. You also did a little bit of Haritaki, it is contraindicated when Pitta is high, unlike Triphala which is indicated.

Dario- Yes, I thought of Haritaki because when I saw the tongue, the coating was on the back of the tongue.

Vaidya- Once you do the purging with Triphala instead of Haritaki it will improve the condition. Bhav Prakasha is saying that pregnant women and the people who have high Pitta should not be given Haritaki because it is going to exacerbate the Pitta symptoms. I think that the case is simple, it’s not to be worried about you can ask him about how you understand his condition now and you want him to purge and get everything out of his system because whatever herbs that you gave him melted all the cholesterol and brought to the system but they haven’t purged yet. I think that would be the best way to go further and after the purging is done then you can go to Amalaki or Bhumyamalaki or Bhringraj or Bhunimba things like that which will then restore the liver function.

Dario- This is after 3 weeks?

Vaidya- Yes and I think that should be enough for him as those will be the best protocols to do. I would be curious to see what happened after the purging.

Dario- I hope he’d be willing to do it.

Vaidya- Yes, you just have to tell him that all his cholesterol came down because all the toxins were melted and now they are in the blood circulation and I want to purge them out. Thank you Dario you for this wonderful case study and I am really happy that you are dealing with these types of cases. Ayurveda definitely can be a great resource for these cases, your choices were correct the only thing was in the end you have to purge it.

Dario – It’s similar to what happened to me as it seems like I’m missing all the purging.

Vaidya - If anything you can always let me know if you need any help further, so I’ll be able to help you.

Dario- I have one more question-would prune juice would have worked?

Vaidya- No because it is sweet and it only purges the gut but you want something bitter, astringent, sour, and pungent which Triphala has, to draw it out of the body. Prune juice only eliminates it from the gut but you want it to draw this out and then purge it. That's only done by Triphala.

Dario- That was interesting.

Vaidya- This is a learning phenomenon, and we do learn from what we have done as a mistake and then we continue. It is from my experience that I’m saying and I am glad that you are doing the same thing as well. I think all our listeners and practitioners would be very much vibrating with you because things like these are very common in our practice. I appreciate you bringing this case to us and I look forward to welcoming you again with another case or maybe this case in the next two months to see how the response was. Thank you to Dario and our listeners for listening to this podcast about Ayurvedic case management as a part of our Ayurvedic professional services that we provide through Athreya herbs. I look forward to bringing you another interesting case, Namaste.

Dario-Thank you Vaidya Jay, Namastey.

Herb recommendations- Triphala Guggulu, Shilajit, Guduchi, Kanchanar Guggulu, Trikatu, Haritaki, Avipattikar, and Triphala powder, Amalaki, Bhunimba, Bhringraj, Bhumiamalaki