Treatment Protocol

Name of Disease: Ayurveda (Modern): Pandu is a disease characterized by discoloration of

skin. The colour of the skin may be change to pallor, yellowish, greenish or any other color.
There is diminution of Rakta (blood)1 mainly oxygenated (hemoglobin) as its site of origin is
heart and it circulate through Dhamani (artery). On the basis of pathology and clinical features it
can be correlated with Anemia.
Nidana (Causative Factors):
1. Ahara- Viharajanya (dietary and life style factors)
2. Nidanarthakara roga
Diagnostic criteria and various presentation/ phases of the diseases:
1. Clinical Parameters:
a. Symptoms:
Karnakshweda (Tinnitus)
Hatanala/ Agnisada (Loss of digestion)
Dourbalya (weakness)
Sadana (malaise)
Annadvesha (anorexia)
Shrama (Exhaustion)
Bhrama (giddiness)
Gatrashoola(bodyache)
Jwara (fever)
Shvasa (dyspnea)
Gaurava (heaviness)
Alpavaak (Diminished speech)
Pada Ruk (Pain in feet)
Arohanayasa (Exertion on climbing stairs)
Shishiradveshi (intolerance to cold)
Nidralu (drowsiness)
Kopana (irritability)
Pindikoudrestana (intermittent claudication)
Kati-uru-pada ruka (muscle spasm)
b. Signs:
local
Vivarnata: Pandu varna (pallor)
Shunakshikuta: Periorbital swelling
Hridayaspandana: Tachycardia/ Haemic murmur
Hataprabha: loss of normal luster of the body
Rukshata: Roughness of skin
Harita: loss of body weight
Systemic: Mouth:

Angular stomatitis
Gum hypertrophy
Glossitis
Bald tongue
Raw beefy tongue

Skin & Nails:

Telangiectasia
Purpura/ Brusing
Koilonychia
CVS:
Tachycardia
Water- hammer pulse
Haemic murmur
G.I.T
Hepatosplenomegaly
R.S
Basal Crepitations
N.S
Papillodema
Other:
2. Laboratory Parameters:
A. Routine: Full blood count (FBC)/ complete blood count (CBC)
Main parameters measured

Hb concentration, MCV, MCH, MCHC, Haematocrit (Hct) or PCV, Red cell

distribution width (RDW), White cell count (TLC), WBC differential,
Platelet count (DLC), Full blood count (FBS),Peripheral blood smear.

B. Specific: Serum ferritin, Serum Iron and Total Iron-Binding Capacity, Bone
marrow examination
C. Others:
Evaluation for hemosiderinuria, hemoglobinuria, and pulmonary
hemosiderosis
Hemoglobin electrophoresis and measurement of hemoglobin A2 and fetal
hemoglobin
Reticulocyte count
D. Tests useful for establishing the etiology of iron deficiency anemia and excluding or
establishing a diagnosis of another microcytic anemia include the following:
Stool testing
Incubated osmotic fragility testing
Measurement of lead in tissue
Bone marrow aspiration
Differential Diagnosis:
Vatika Pandu

Iron deficiency
Anemia

Krishnapanduta
(black and pale
yellow
complexion),
Rukshata
(ununctuousness
Angamarda

Paittika Pandu

Megaloblastic
Anemia

Pita-abha
(yellow
complexion
Jwara (fever),
Daha (burning
sensation),
Trishna

Kaphaja Pandu

Sannipataja
Pandu

Anemia of
Chronic Disease

Sickle Cell
Anemia/
Thalasemia/
Aplastic
Anemia

Symptoms of
all three
doshas.

Gourava
(heaviness),
Tandra
(drowsiness,
Cchardi
(vomiting),
Sveta-

Mritrikabhakshanajanya
Pandu
Hook worm infested
Anemia

Shuna-gandaakshikuta-bhru
(swelling in the
check, eyelids and
eye brows)
Shuna-pada-nabhi
(pedal and umbilical

(malaise),
Ruja (pain),
Kampa (tremor),
Anaha
(constipation),
Balakshaya
(weakness), etc.

Iron deficiency
Anemia

General fatigue
weakness
pale skin
shortness of
breath
dizziness

(excessive
thirst),
Murcha
(faints),
Pitamutra
(yellow
micturation)
Amla-udgara
(sour
eructation,
Tama
(fainting)
Bhinnavarcha
(diarrhea)
Dourbalya
(Weakness)

Megalobastic
Anemia

tingling or a
crawling feeling
in the legs
swelling or
soreness in the
tongue

oedema),
Atisara (loose
motions)
Krimi-kostha (worm
infestation)

Anemia of Chronic
Disease

Aplastic Anemia
(Pitta dominated
Sannipataja
Pandu)

Lemon- yellow

Pale complexion,

Fatigue

discoloration of

lightheadedness,

skin/ abnormal
pigmentation

fatigue,

Shortness of
breath with
exertion

weak muscles

Fever

numbness or
tingling in hands
and feet

rapid heartbeat

difficulty
walking
glossitis

Sickle Cell
Anemia
(Vata dominated
Sannipataja
Pandu)

Thalassemi
a

Severe pain

Anemia

Chest pain and

People who
have alpha
or beta
thalassemia
trait can
have
mild anemia.

Cough

Rapid or irregular
heart rate

Dyspnea

Pale skin

Nausea
Weakness

strange cravings
for non-food
items, such as
dirt, ice, and clay

ababhasata
(white
complexion,
Praseka
(salivation),
Lomaharsha
(horripilation),
Shwasa
(breathlessene
s)
Kasa (cough),
Aruchi
(anorexia).

malabsorption,
such as weight
loss, abdominal
distention,
diarrhea, and

breathing

Strokes

Joint pain and

Frequent or
prolonged
infections

arthritis and bone

infarctions

Unexplained or
easy bruising

Blockage of blood

Nose bleeds and

bleeding gums

or liver

nausea
signs of

difficulty in

Prolonged
bleeding from
cuts

flow in the spleen

Severe infections

People who
have beta
thalassemia
intermedia
have mild to
moderate
anemia and
they have:
slowed
growth and
delayed
puberty,
bone
problems
and an
enlarged

cold hands and

feet

steatorrhea.

Skin rash

spleen

evidence for
fast or irregular
heart beat

achlorhydria

brittle nails

abdominal

headaches

Dizziness

such as
Headache

discomfort, acid
reflux, early
satiety, and
abdominal
bloating
decreased
appetite
irritability
lack of energy or
tiring easily
(fatigue)
diarrhea
smooth and
tender tongue
increased heart
rate
(tachycardia)

People who
have
hemoglobin
H disease or
beta
thalassemia
major (also
called
Cooley's
anemia)
have severe
thalassemia
and have
A pale and
listless
appearance
Poor
appetite
Dark urine
(a sign that
red blood
cells are
breaking
down)
Slowed
growth and
delayed
puberty
Jaundice (a
yellowish
color of the
skin or
whites of the
eyes)
An enlarged
spleen, liver,
or heart
Bone
problems
(especially
with bones
in the face)

Complications
If the disease is not treated, then following complications may arise:
1. Aruchi (anorexia)

2. Pipasa (thirst)
3. Cchardi (vomiting)
4. Jwara (fever)
5. Murdha Ruja (headache)
6. Agnisada (dyspepsia)
7. Kanthagata Sotha (oedema in throat)
8. Abalatwa (weakness)
9. Murcha (fainting)
10. Clama (fatigueness)
11. Hridaya Pidana (cardiac pain)
Anemia may have following complications:
1. Severe fatigue, Restless legs Syndrome
2. Arrhythmia, Heart failure
3. Neurological complications in Megaloblastic anemia
4. Death
Prognosis of Disease: Incurable if following signs & symptoms are present:
Chirotpanna (chronic)
Sotha (oedema/ anasarca)
excessive pallor
visual hallucination (see everything yellow)
loose greenish stool with mucous
Vomiting
Syncope
Thirst
Excessive depletion of Rakta dhatu

Modifiable/Avoidable Life style factors (Specific only):

Aahara: Consumption of peas, cooked leaves, asafetida, urada peas, sesame cakes, betel
leaves, liquor, red chilies should be avoided. Avoid excessive intake of Kshara, Amla,
Lavana, Ushna,Viruddha and Asatma food. Excessive intake of Nispava, Masha,
Pinyaka, Madya and Tila Taila should also be avoided. Diet deficient of iron, vitamins,
folic acid causes anemia.
Vihara: Blood-letting, smoking, Svedana, Vamivegavidharana (retaining the urge of
vomiting), Sleeping during day time, exercise as well as sexual intercourse even before
the food is not properly digested should be avoided. Vega Vidharana, excessive
Vyayama, etc. and affliction of mind with Kama, Cinta, Bhaya, Krodha and Shoka causes
indigestion and Ama production therefore should be avoided for proper formation of
dhatus.
Treatment Protocol:
1. Principle of Treatment:
In Pandu, Doshapratyanika chikitsa is mentioned in Samhita along with
Vyadhipratyanika chikitsa. Physician can better applied Ubhyapratyanika chikitsa for better
management of Pandu.
Vyadhipratyanika chikitsa
Doshapratyanika chikitsa
Ubhayapratyanika
Vyadhipratyanika Chikitsa :
Nidanarthakara Roga
Specification of Disease (if any):

vyadhisankara

None

Kupitavatajanya
Avaranajanya
Any other
Nidanarthakara Roga:
Anubandhya Vyadhi (Main disease):
Anubandha Vyadhi (Associated complications):
Assessment of Vyadhibala (on the basis of involvement of dosha, marga, etc) :
Pravara
Madhyama
Avara
Assessment of Aturabala ( on the basis of Sara, Samhana, Satva, Satmya, etc):
Pravara
Madhyama
Avara
Assessment of Vyadhi and Atura Bala
Rogabala Pravara Rogibala Pravara
Rogabala Pravara Rogibala Avara
Rogabala Avara Rogibala Pravara
Rogabala Avara Rogibala Avara

Samsodhana Chikitsa
Samsamana Chikitsa
Nidanaparivarjana Chikitsa
Samsamana Chikitsa

Doshapratyanika Chikitsa (Consider only Samchaya, Prakopa and Prasaravastha of

Dosha):
Prakriti:
Vikriiti:
DoshaDushyaSrotasaSamuthanaType of Treatment modality provided:
a. Asuri Chikitsa (Surgical)
Manusi Chikitsa (Herbo-mineral)
Daivi Chikitsa ( Rasa
Chikitsa)
b. Daivavyapashraya Chikitsa (Spiritual therapy)
Yuktivyaprasraya Chikitsa (Rational
approach)
Satvavajaya Chikitsa (Psychotherapy)
c. Samsodhana Chikitsa

Samsamana Chikitsa

Both

Type of Treatment according to the stage of disease:

a. Acute stage

b. Chronic (Kaphaja)

Vaitika type (pain dominated)

Paittika type (having dominated inflammatory signs)
Specification of Treatment according to disease:
Chikitsa Sutra (Principle/ line of treatment according to text):
Samanya Chikitsa (general treatment):
Patients of Panduroga should be treated firstly by Snehana followed by Shodhana
therapy using Snigdha and Tikshna drugs and finally Raktavardhaka regimens should be
prescribed.
Samsodhana Cikitsa:
Snehana
Vamana
by Snigdha and Tikshna drugs
Virecana

Vishishta Chikitsa (specific treatment)

Type
1.
2.
3.
4.

Chikitsa sutra
Snehanam (ghritpana)
Tikta rasa+ sheeta virya drugs
Katu-tikta rasa+ ushnavirya drugs
Nidan parivarjanam+ krimi upachara+
balya ghrita
Ghrit pana for snehana: Dadimadi ghrita, Draksha ghrita, Mahatiktaghrita, Kalyanakghrit,
Panchgavyaghrita
Samsamana Chikitsa:
Vataja
Pittaja
Kaphaja
Mridbhakshanjanya

Classical drugs with Anupana:

Rasa/ Bhasma/Pisti
Dose: 125mg- 250mg twice in a day/ dose may be titrated by the physician
Anupana: luke warm water/ luke warm milk/ honey etc.
Punarnava mandura, Navayasa louha, Sothari louha, Vidangadi louha,
Svarnamakshika bhasma, Tapyadi louha, Dhatri louha, Yogaraja,
Su.Mandura bhasma, Louha bhasma, Su Kasisa bhasma, Sankha bhasma,
etc.

Vati
Dose: 1-2 tablets twice in a day/ dose may be titrated by the physician
Anupana: Vatasamaka Kwatha/ luke warm water
Arogyavardini vati, Mandura vataka
Curna
Dose: 3-6g twice in a day/ dose may be titrated by the physician
Vishaladi curna, Triphala curna, Amalaki curna, etc.
Kvatha
Dose: 40-80ml twice in a day/ dose may be titrated by the physician
Phalatrikadi Kvatha, Punarnavastka kvatha,etc.
Asava/Arista/ Arka
Dose: 10-20ml twice in a day/ dose may be titrated by the physician
Kumaaryasava, Louhasava, Punarnavasava, Vidangarista, Drakshasava,etc.
Avaleha
Dose: 10-20ml twice in a day/ dose may be titrated by the physician
Anupana: Luke warm water/ Luke warm milk
Dhatryadi leha, Darvyadi leha, Drakshavleha,etc.
Ghrita
Dose: 10-20ml twice in a day/ dose may be titrated by the physician

Anupana: Luke warm water/ Luke warm milk

Rohitakadi ghrita, Triphala ghrita, Kalyanaka ghrita, Mahatikta ghrita,etc.
Rasayana
Dose: dose decided by the physician according to patient strength.
Anupana: luke warm milk/ luke warm water
Yogaraja rasayana, Triphala Rasayana, Amalaki Rasayana, Silajita
Rasayana, Louha Rasayana, Gomutra Haritaki, Cyavanaprasha,
Mandura Rasayana,etc.
Scientific Explanation of Treatment:
As already described that Pandu is predominantly due to lack of blood, or in other words it can
also be said that, in Pandu there is diminution of its main constituents which along with other
factors play major role in the normal erythropoesis, causing development of
Anemia. Correction in these constituents and other associated factors will naturally be followed
in increased blood production and ultimately improvement of Anemia or Pandu.
On the basis of the recent studies which have been dealt in connection with the normal
erythropoiesis, it is seen that the deficiency of following substances have got important role in
the development of Anemia and thus, their use has been specifically advocated in the treatment
of Anemia. They are Iron (Lauha) - From times immemorial the role of lauha (iron) in the treatment of Pandu
is well known to the Indians. The fact that lauha is closely related with formation of
blood was well realized and that is why Rakta has also been known by the word Lohita,
and Pandu by the word Vilohita. Almost all Ayurvedic Samhitas have clearly mentioned
the use of lauha preparation in the treatment of Pandu. In this connection, a verse from
Vagbhatta is important (Pandavamayo Shreshtha).
Tamara (Copper) - It should be born in mind that all iron salts that have not been
chemically purified usually contain traces of copper. Catalytic action of Tamara for
proper metabolism and absorption of iron is well established.
Cobalt - The use of cobalt in the treatment of Anemia has been confirmed by modern
workers. It acts by stimulating the production of erythropoitin which stimulates
erythropoisis.
Calcuim - Use of Shankha bhasma along with various iron preparations is used in the
treatment of Pandu. The role of Calcium in conversions of the iron has been confirmed
by modern workers.
Among the other drugs important origin which have been described in Ayurvedic text in the
treatment of Pandu are - Tamra, Anjana, Swarna, Gairika, Mandura, Shilajeeta etc.
Now the other most important group of specific drugs acting in Anemia or Pandu is haeamatinic
principles consisting of extrinsic and intrinsic factors.
Now - a - days, Vitamin B12 and folic acid is used in the treatment of Anaemia, proving the
earlier findings of Sushruta and Vagbhatta.
The use of other vitamins and minerals, hormone as for example Riboflavin, Niacin, Pyridoxine,
Ascorbic acid and hormones like Androgenic hormone, Thyroxine, testosterone, Prolactin has
been employed in the treatment of various types of deficiency Anemias.

Treatment Plan A
Mild to Moderate Anemia (Hb g/dl, F = 8- 11.5g/dl, M= 8- 12.9g/dl)*
Vatika Pandu

Paittika Pandu

Kaphaja Pandu

Mritrikabhakshanajanya
Pandu

Aim of the treatment

1. Raktavardhaka
2. Vatashamaka/
Vatanuloomaka
Chikitsa

1.Agnideepana and
Pittashamaka
chikitsa
2. Raktavardhaka
3. Raktavaha
srotomula chikitsa

1. Agnideepana
and Amapachana
chikitsa
2. Raktavardhaka
3. Rasayana
chikitsa

1. Trikshna Samsodhana
2. Doshapratyanika
chikitsa

Management
1. Lauha/ Mandoora
preparation like
Navayasa louha,
Tapyadi louha, etc.
can be given in
appropriate dose.
2. Accha sneha or
sneha pravicharana
can be given
assessing the
Agnibala of the
patient.

1. Drugs having
Pittashamaka and
Agnivardhaka
properties like
Arogyavardhini,
Sutasekhara rasa, can
be added.
2. Lauha preparation
like Dhatri louha
(pittashamaka +
raktavardhaka) can be
given in appropriate
dose.
3. Drug acting on
raktvaha sroto-mula
(liver) should be
added*.

1. Drugs having
digestive action like
Trikatu,
Dadimastaka,
Lavanbhaskara, etc.
can be added for
Agnideepana and
Amapachana.

1. Drugs indicated for

parasitic infection liker
Vidangadi lauha,
Vidangarista, etc. should be
added in appropriate dose
after proper Samsodhana.

2. Lauha preparation
like Punarnava
mandoora, Sothari
lauha or Tapyadi
lauha can be added
according to
presenting associated
symtoms.
3. Rasayana like
Yogaraja, Amalaki
Rasayana, etc should
be added to replenish
depleted dhatus.

Iron is well absorbed/ tolerated when supplemented with Vitamin C, therefore lauha or mandoora
preparations should be supplemented with Amalaki curna/ Amalaki rasayana. Copper as a
supplement to iron enhances hemoglobin synthesis. Thus drugs having lauha and tamara are
better for hemoglobin synthesis.

Vatika, Paitika or Kaphaja Pandu may be found associated with Krimijanya Pandu (as in
India Iron deficiency anemia due to hook worm infestation is the most common type of
anemia),therefore it is advisable to add krimighana drug with treatment.
Liver is supposed to play an important role in the metabolism of iron. Ascorbic acid
chelates in iron absorption is a role for hydrochloric acid and bile.

Treatment Plan B
Moderate Anemia (Hb g/dl, F=8-10.9 g/dl, M= 8-10.9g/dl)* with Complications
Vatika Pandu

Paittika Pandu

Kaphaja Pandu

Mritrikabhakshanajanya
Pandu

Aim of Treatment
Management of
Vatika
complications like
growth retardation,
restless leg
syndrome, etc.
1. Vatashamaka
drugs and
procedures (Basti)
should be added
with hematinic
drugs .
2. Rasayana mainly
Hridya rasayana
(cardiotonics) like
Arjuna.

Management of
Paittika complications
like sepsis, enlarged
spleen, etc.

Management of
Cardiovascular and
renal complications

Management of Tridoshaja
complications

1. Raktasodhaka,
Raktavardhaka and
Raktaprasadhaka all
the three are applicable
for the proper
management of
complications.
2. Raktavaha
srotomula chikitsa.
3. Rasayana chikitsa

1. Rasayana
working on hridaya
as well as basti can
be given.

1. Raktastambhaka chikitsa
if there is bleeding with
stool.

2. Agnideepana and
Amapachaka drugs
should be given.
3. Raktavardhaka
chikitsa

2. Apakarshana,
Prakritivighata and Nidana
Parivarjana
3. For Apakarsana of krimi
trikshna virechana can be
given assessing patient
strength and maintain proper
fluid balance.
4. Rasayana Chikitsa

Treatment Plan C
Severe Anemia (Hb< 8g/dl in both Male & Female)

Raktabasti Acharya Charaka mentioned Raktabasti in severe Anemia.

Blood transfusions in those without symptoms is not recommended until the hemoglobin
is below 60 to 80 g/L (6 to 8 g/dL). In those with coronary artery disease who are not
actively bleeding transfusions are only recommended when the hemoglobin is below 70
to 80g/L (7 to 8 g/dL). Transfusing earlier does not improve survival. Transfusions
otherwise should only be undertaken in cases of cardiovascular instability

*Hemoglobin concentrations for the diagnosis of anaemia and assessment of severity.Vitamin

and Mineral Nutrition Information System. World Health Organization.
Indication of some Lauha Preparations
1. Navayasa Lauha- (Triphala, Trikatu, louha, Trimada, etc.) mainly indicated for Anemia
associated with cardiac disease (tachycardia, arrhythmia, etc.), Jaundice and Hemorrhoids.
2. Tapyadi lauha- (Triphala, Trikatu, Shilajatu,etc.) indicated
3. Dhatri lauha- (Amalaki, haridra, Louha, trikatu, etc.) mainly indicated for Anemia associated
with Jaundice.
4. Punarnava Mandoora- (Trikatu, vidanga, trivrita, haridra,louha,etc.) mainly indicated in
Anemia associated with ascites, oedema, parasitic infection and piles.
5. Sothari Lauha- mainly indicated in Anemia associated with oedema (pedal odema/ anasarca).
6. Vidangadi lauha- (Vidanga, triphala, trikatu, etc.) mainly indicated in Anemia due to
parasitic infection.
7. Saptamrita lauha- indicated in anemia associated with headache.
Sample of Prescription:
1. Navayasa Lauha
2. Arogyavardhini
3. Vidangarista
4. Amalaki Rasayana
5. Haritaki curna

- 2 tab B.D.
- 2 tab B.D. (before meal if wish to work on Samana Vayu)
- 4 TSF after meal with equal amount of water
- 1 TSF B.D. with milk
- ITSF H.S. with luke warm water.

If Iron preparation does not have triphala or amalaki as an ingredient, then these should be
added separately.

Reference