Literature Review on Siddha Herbal Formulations ( Kudineer ) Available for The Management of Dengue

Dengue is a major threat to public health in many countries. There is no vaccine to prevent the infection. In spite of management of the disease with conventional method of treatment, mortality due to dengue is increasing year by year. In India, state of Tamil nadu during 2012 dengue crisis, initiated a new model by including traditional Siddha medicines along with conventional therapy for management of dengue in government hospitals. The result of the initiation was a great success, as the Siddha medicines showed remarkable clinical improvement. As there is no effective dengue specific antiviral drug is available and the widely used NSAIDs show anti platelet activity, there is a need for Siddha formulations to be explored scientifically. This review focuses on Siddha kudineer formulations for dengue. Kudineer formulations include only dried and grinded herbals. The method of preparation of kudineer is simple and the phyto constituents do not undergo any major change while processing and preparation, unlike other traditional formulations. Ingredients of the formulation and their pharmacological action are discussed in the review. The review may act as a keyhole for the dengue drug development.


INTRODUCTION
Today dengue ranks as most important mosquito borne viral disease in the world.WHO estimates that 50-100 million dengue infections occur each year and almost half of the world's population lives in the countries, where dengue is endemic.Close to 75% of global population exposed to dengue are in Asia-Pacific region. [1]ere are no antiviral medicines available for dengue.Current conventional management focuses on fluid replacement and management of other metabolic consequences of viral infection.
A major problem in fight against virus is rapid adaptation and development of drug resistance as well as emergence of new hybrid viruses.In past few years natural remedies came more and more in centre of interest.Recent studies showing antiviral potential of plant extracts against viral strains resistant to conventional antiviral agents have challenged modern drug discovery practices and deem a very careful look towards exploring natural antiviral components of medicinal plants and exploring traditional medical formulations used in treatment of viral diseases.

Siddha medicine
Siddha medicine is the traditional medical system widely practised in South India.History of Siddha medicine dates back to many centuries.It was enriched with ethnic medical knowledge of Tamil people, native of rich biodiversity zone of Western Ghats.Their trade and cultural contacts with China, Europe and Middle East countries as a hub point in the spice route enabled them to exchange their knowledge of ethno pharmacognosy with other traditional medical systems in the world.The heritage of medical knowledge was further developed by Siddhars, a group of saints with goal of immortal human body and soul.Siddha medical formulations are based on three kutram and panchabootham philosophy.

Dengue
Dengue fever is an acute febrile illness caused by virus belonging to Flaviviridae family.Four well defined dengue viruses identified are DENV-1, DENV-2, DENV-3 and DENV-4.Each of them has a distinct genetic structure.Dengue virus is transmitted to humans through bites of infective Ades mosquitos-Ades aegyptii, Ades albopictus.Dengue fever is characterised by biphasic fever, myalgia, arthralgia and rashes.Dengue haemorrhagic fever is characterised by abnormality in haemostasis and by marked leakage of plasma from the capillaries.The later may lead to Dengue shock syndrome. [2]

MATERIALS AND METHODS
The review process is adopted to collect various Siddha Kudineer formulations for the indication Pitha suram mentioned in published Siddha texts.Pitha suram is the equivalent term in Siddha for Dengue (Table 1).The data is summarised and list of herbs used in the formulations are identified.The pharmacological activity of each herb, identified by standard scientific procedures and documented in open access scientific journals is sorted out by searching in internet with their botanical name as keyword.

Inclusion and exclusion criteria
Only the Kudineer formulations are included.Other formulations such as Ilagam, Mathirai, Nei etc are not included in the review.Kudineer formulations with mineral or metal salts, pure metals and animal products as ingredients are excluded from the review.

Pithasuram and Dengue comparison
Dengue is endemic in Southeast Asia and India. [3]istribution of countries at risk of dengue transmission lies in between 10 O C January isotherm and 10 O C July isotherm. [4]As the homeland of Siddha, Tamilnadu lies in centre of this zone; it was prone to dengue since centuries.So the traditional medical system is well aware of the disease.It categorise dengue as Pithasuram, one of 64 Suram or Fever.Symptoms of Pitha suram mentioned in Siddha literatures, Agasthiyar Sura Nool 300, Suravakadam and Siddha maruthuvam (Pothu) can be correlated with symptoms of dengue. [4]dineer Kudineer is the common name given to the Siddha formulation in which the whole plant (s) or particular part of plant (s) is grinded into coarse powder, called as 'kudineer choornam'.'Kudineer choornam' is then made into kudineer by adding water and heated, so that the mixture of kudineer choornam and water reduces to 1/4 th or 1/8 th of its volume as mentioned in the literature.Dose of the kudineer is generally 30ml before food, three to four times a day.Lifetime of prepared kudineer is 1 Samam (3 hours).

Nilavembu
Whole Plant
Review on Siddha kudineers for Dengue.
There is no any dengue specific antiviral drug.Antiinflammatory drugs such as NSAIDs inhibit platelet cyclooxygenase and block the formation of Thromboxane A2.Thromboxane A2 is essential for platelet aggregation.So NSAIDs should not be used in treatment of dengue as it may aggravate bleeding tendency.There is a great need for effective anti-inflammatory drug which will not interfere in clotting mechanism.
Herbal ingredients of Siddha Kudineer formulations have antiviral, anti-inflammatory and immune modulator activity.It is evident from Table .2and is summarised below, The ingredients used in Siddha kudineer formulations were already evaluated for their antipyretic, anti-inflammatory, antiviral and immunomodulatory activity (Table 3).Their pharmacological properties must be confirmed; active principles traced and clinical studies may be conducted using these polyherbal formulations.As there is a lack of effective antiviral and anti-inflammatory drugs for the treatment of dengue, Siddha formulations may be explored to fill up the vacuum.