Comparative Review of Avipattikar Churna and Sutshekhar Rasa in the Management of Acid-Peptic Disorders: Current Evidence and Future Perspective

Acid-peptic disorders (APDs) are one of the most common diseases that affect a huge proportion of the population worldwide, contributing to significant economic burdens and negative impacts on the quality of life. Peptic ulcer disease (PUD) is among the most prevalent and common gastrointestinal disorders, characterized by breaks in the gastric or duodenal mucosa. Despite the variety of diagnostic and therapeutic strategies, peptic ulcer disease remains a major health problem in terms of recurrence, complications, and treatment failures. PUD is a multifactorial disease that is primarily due to an imbalance between aggressive and protective factors. The aggressive factors consist of hydrochloric acid and pepsin, Helicobacter pylori infection, non-steroidal anti-inflammatory drugs, alcohol, smoking, stress, and oxidative stress. Protective factors are mucous-bicarbonate barriers, prostaglandins, mucosal blood flow, epithelial cell renewal, and endogenous antioxidants. The damage to the integrity of the mucosal lining results in complications such as ulceration, bleeding, perforation, gastric outlet obstruction, and mortality. [5,6,7]

The incidence and prevalence of acid-peptic disorders have skyrocketed in the past years due to unhealthy lifestyles, poor dietary habits, the intake of processed foods, alcohol consumption, and smoking. The use of non-steroidal anti-inflammatory drugs, stress, and Helicobacter pylori infection also contribute to these disorders. The conventional treatment strategy for acid-peptic disorders entails the use of proton pump inhibitors, histamine H2-receptor antagonists, antacids, and mucosal protective agents to reduce the production of gastric acid or treat the infection. The treatment regimen also includes antibiotics which help in eradicating H. pylori infection. However, this therapeutic approach has several limitations which are linked to adverse effects such as treatment failure, recurrence of infection after treatment discontinuation, drug-drug interactions, nutrient deficiency, and development of bacterial resistance to antibiotics. These flaws in conventional therapy have prompted medical researchers to develop an alternative therapeutic agent with desirable effects. [8,9]

The traditional system of medicine, including Ayurveda, has played an essential role in the management and prevention of various diseases, including acid-peptic disorders. The disorders associated with excessive gastric acidity, characterized by heartburn and sour taste in the mouth, are referred to as Amlapitta in Ayurveda. [10,11]

It is caused by the imbalance of Pitta Dosha, improper diet, incompatible food, stress, and a sedentary lifestyle. The manifestations of Amlapitta include sour belching (Amlodgara), burning pain in the epigastrium (Hrit-Kantha Daha), nausea (Utklesha), vomiting (Chardi), anorexia (Aruchi), abdominal discomfort, and indigestion. The management of Amlapitta is aimed at balancing the aggravated Pitta and reducing the symptoms through the use of appropriate diet and lifestyle changes, Shodhana (cleansing) therapies, and the administration of the drugs with Deepana (appetizer), Pachana (digestive), Pitta-Shamaka (Pitta-reducing), Ropana (healing), antioxidant, anti-inflammatory, and gastroprotective properties. [12]

Among the wide range of formulations recommended for the treatment of Amlapitta, Avipattikar Churna and Sutshekhar Rasa are the most commonly prescribed ones. Avipattikar Churna is a classical polyherbal formulation with remarkable carminative, antioxidant, anti-inflammatory, laxative, and gastroprotective activities. It has been proved that Avipattikar Churna possesses anti-secretory, antiulcer, antioxidant, and mucosal protective effects, which contribute to the healing of various gastrointestinal tract disorders. Sutshekhar Rasa is a classical herbo-mineral formulation indicated for Amlapitta, sour belching, heartburn, nausea, vomiting, and other Pitta-related conditions. It has been shown that Sutshekhar Rasa has Pitta-balancing, digestive, anti-ulcer, and gastroprotective effects. Both formulations have been used in clinical practice for a long time, and their effectiveness has been confirmed by numerous studies. However, there are significant differences between these two formulations in terms of composition, pharmacological properties, and the extent of scientific evidence. [13,14,15]

In the past two decades, there has been an increasing interest worldwide in exploring the use of traditional medicines, one of which is Ayurveda. Therefore, there is a need for further experimental and clinical studies using modern science methods to identify the phytochemistry, pharmaceutical, pharmacological, and toxicological potentials of Ayurvedic drugs, prove their clinical effectiveness, and safety. Avipattikar Churna was proved to possess gastroprotective and antiulcer effects through several experimental and clinical studies. The majority of the available studies on Sutshekhar Rasa have investigated its pharmacological effects, quality assurance, and clinical applications in terms of the management of Amlapitta. The data about these two drugs are complex, extensive, and disconnected, which makes it difficult to identify the relationship between them. [16,17,18,19]

Although both of the medications are considered to be effective in the management of acid-peptic diseases, there is a lack of reviews comparing their clinical application and pharmacological potential according to the modern evidence-based medicine principles. The majority of the published articles describe the phytochemical, pharmaceutical, pharmacological, and clinical properties of Sutshekhar Rasa and Avipattikar Churna individually, rather than comparatively. [20]

Besides, there is a need for further preclinical and clinical studies to explore the experimental antiulcer activity, as well as the safety and efficacy of Avipattikar Churna and Sutshekhar Rasa. [21]

Therefore, it is of great interest to compare the classical Ayurvedic formulations Avipattikar Churna and Sutshekhar Rasa in terms of their use in the management of acid-peptic disorders. The present review aims to analyze the available data on the classical background, composition, pharmacological effects, experimental antiulcer activity,  safety, and future perspectives of Avipattikar Churna and Sutshekhar Rasa. [22,23,24]

PATHOPHYSIOLOGY OF ACID PEPTIC DISORDERS

Acid-peptic disorders encompass various diseases related to dyspepsia attributed to the reduced gastroduodenal defensive capability against aggressive factors and the presence of damaging elements. The gastric mucosa is exposed to highly corrosive agents like acid and pepsin secretions and external irritants such as non-steroidal anti-inflammatory drugs (NSAIDs), alcohol, and Helicobacter pylori infection. The gastric mucosa utilizes defence mechanisms against these corrosive elements, including mucous and bicarbonate secretion, prostaglandin synthesis, adequate mucosal blood flow, epithelial cell renewal, and junctional integrity. The protective function and restitution process of the mucosa are disrupted by several damaging agents, resulting in ulcers. [25,26,27,28]

Chronic gastroduodenal inflammation caused by the helical-shaped bacterium known as Helicobacter pylori leads to reduced protection of the mucous membrane, thereby facilitating ulceration. The bacterium Helicobacter pylori causes the production of gastrin, which in turn provokes increased secretion of gastric juices by the stomach, creating an ulceration risk factor. Moreover, Helicobacter pylori reduces bicarbonate secretion and prostaglandin synthesis, weakening the mucosal protective mechanism, which ultimately promotes the occurrence of an ulcer. On the other hand, NSAIDs cause gastroduodenal damage through cyclooxygenase isoenzyme inhibition, resulting in reduced mucosal blood flow and impaired mucus production. The other causes of gastroduodenal ulcers include heavy alcohol consumption, smoking, stress, unhealthy eating habits, bile reflux, and genetic predisposition. [29,30,31]

The production of reactive oxygen species (ROS) leads to oxidative stress, which aggravates the severity of damage to the gastrointestinal mucosa. The increased production of free radicals over antioxidant availability leads to lipid peroxidation, mitochondrial malfunction, DNA damage, cell death, and decreased production of endogenous antioxidants. Oxidative stress also causes impaired epithelial restitution resulting in ulceration and erosion of the gastric mucosa. Inflammation and oxidative injury to the gastric mucosa are key pathological features of acid-peptic disorders. As a result, acute upper gastrointestinal complications including hemorrhage, perforation, and gastric outlet obstruction are frequent causes of morbidity and mortality. [32,33,34]

The various etiologies and pathophysiological mechanisms of acid-peptic disorders require the development of comprehensive therapeutic strategies. A therapy that promotes epithelial cell proliferation and reduces oxidative stress has a restitutive effect on gastric mucosa. An effective treatment regimen for acid-peptic disease should promote mucosal healing and protect the mucosa from further injury. This information may be used to formulate ayurvedic formulations for the treatment of acid-peptic disease. [35,36]

COMPARATIVE REVIEW OF AVIPATTIKAR CHURNA AND SUTSHEKHAR RASA           

Avipattikar Churna and Sutshekhar Rasa are two classical Ayurvedic formulations used for the management of Amlapitta and other acid-peptic disorders. Both preparations are used for the treatment of similar diseases; however, they differ significantly in terms of composition, pharmaceutical nature, therapeutic concepts, and the level of scientific evidence. Avipattikar Churna is a polyherbal formulation containing medicinal plants as the main components with proven therapeutic properties. At the same time, Sutshekhar Rasa is a famous herbo-mineral preparation which includes herbal and purified mineral ingredients. The difference in the composition of the preparations is reflected in their pharmacological properties, mechanisms of action, safety, and various other parameters related to the quality of the formulations. [37,38]

According to Ayurveda, Avipattikar Churna and Sutshekhar Rasa affect the aggravated Pitta and cause it to decrease and restore the balance. In other words, these two preparations help to normalize the functions of the digestive system and eliminate the symptoms of the disease. However, it should be noted that while Avipattikar Churna is traditionally used to treat hyperacidity caused by impaired digestion and constipation due to its laxative effects, Sutshekhar Rasa is indicated in Pitta-type diseases characterized by heartburn, nausea, vomiting, and other accompanying symptoms. [20-24]

The scientific evidence supporting the benefits of Avipattikar Churna and Sutshekhar Rasa is also different. Modern science was able to reveal the exact effect of the ingredients included in Avipattikar Churna, while there is a lack of research describing the benefits of Sutshekhar Rasa. Research studies indicate that Avipattikar Churna exhibits antioxidant, antisecretory, anti-inflammatory, cytoprotective, and antiulcer activities, as well as gastroprotective and laxative effects. By contrast, the evidence for the effectiveness of Sutshekhar Rasa is limited to clinical observations, studies of pharmaceutical standards, and a few experiments conducted. [8-12,25-30]

Thus, it is necessary to compare and analyze the Ayurvedic evidence, scientific data, and pharmaceutical properties of Avipattikar Churna and Sutshekhar Rasa. Especially since the two preparations are used for the treatment of similar diseases but have different compositions that affect their beneficial effects and mechanisms of action. Moreover, Avipattikar Churna has more scientific evidence of safety and efficacy, while the level of proof for Sutshekhar Rasa remains insufficient. Therefore, the following paragraphs will discuss the difference between the classical Ayurvedic concepts, pharmaceutical properties, and scientific evidence for the use of Avipattikar Churna and Sutshekhar Rasa for the management of acid-peptic diseases. This information will allow a better understanding of the benefits and advantages of the two Ayurvedic preparations and their contributions to modern medicine. [13-19,31-40]

COMPARISION OF OF FORMULATION

Composition of Avipattikar Churna

Classical reference: Bhaishajya Ratnavali; Ayurvedic Formulary of India (AFI), Part I. [20,21]

Composition of Sutshekar Rasa

Classical reference: Bhaishajya Ratnavali; Ayurvedic Formulary of India (AFI), Part I. [20,21]

AYURVEDIC PERSPECTIVE OF AVIPATTIKAR CHURNA AND SUTSHEKHAR RASA

From an Ayurvedic perspective, both Avipattikar Churna and Sutshekhar Rasa are classical formulations indicated for the management of Amlapitta, a disorder predominantly caused by vitiation of Pitta Dosha and impairment of Agni (digestive fire). Although both formulations are employed to restore Pitta equilibrium and improve gastrointestinal function, they differ in their therapeutic principles. Avipattikar Churna is a polyherbal formulation possessing Deepana (enhancement of digestive fire), Pachana (digestion of Ama), Pitta-Shamana (pacification of Pitta), and Mridu Virechana (mild purgative) properties. It helps regulate digestion, facilitates the elimination of aggravated Pitta, and is traditionally indicated in Amlapitta, indigestion, and associated constipation. In contrast, Sutshekhar Rasa is a herbo-mineral formulation primarily indicated for Pitta-Shamana and symptomatic management of Amlapitta. The presence of mineral ingredients such as Shankha Bhasma, along with digestive herbal constituents, is traditionally considered to contribute to acid-neutralizing, digestive-supportive, and gastroprotective effects. Thus, while both formulations aim to alleviate Amlapitta, Avipattikar Churna primarily emphasizes correction of impaired digestion and elimination of aggravated Pitta, whereas Sutshekhar Rasa focuses predominantly on Pitta pacification and relief of associated gastrointestinal symptoms [20-24]

COMPARATIVE PHYTOCHEMICAL PERSPECTIVE OF AVIPATTIKAR CHURNA AND SUTHSHEKAR RASA

The differences in phytochemical content make a significant difference in the mechanism of action and pharmacological features of Ayurvedic preparations. Avipattikar Churna is a polyherbal medicine that includes various phytochemicals, such as flavonoids, phenolic, tannins, alkaloids, glycosides, terpenoids, saponins, and essential oils, with significant antioxidant, anti-inflammatory, gastroprotective, and anti-secretory activity. Sutshekhar Rasa is a herbo-mineral preparation that combines the beneficial properties of herbal and mineral ingredients. Information about the phytochemical content of this preparation is limited, but it is believed that the herbal component has diverse metabolic pathways and possesses antioxidant, digestive, and mucosal healing properties. Moreover, the mineral part of Sutshekhar Rasa enhances the therapeutic effects of herbal components rather than providing phytochemicals. [13-19,39,40]

COMPARATIVE PHARMACOLOGICAL PERSPECTIVE OF AVIPATTIKAR CHURNA AND SUTHSHEKAR RASA

Both Avipattikar Churna and Sutshekhar Rasa have proved their pharmacological actions to treat Amlapitta and peptic ulcer disease. They have an antiulcer, gastroprotective effect, antioxidant, anti-inflammatory, Deepana, and Pachana activities. However, Avipattikar Churna is a polyherbal medicine and has a mechanism of action that includes the compounds present in it and their effects on the body, and the herb’s Mridu Virechana activity, which has a detoxicating function. Sutshekhar Rasa, in its turn, is a herbo-mineral preparation that includes minerals like Shankha Bhasma, which are used as an antacid and Pitta-Shamana.. Thus, although both formulations share similar therapeutic benefits, they differ in their composition and mode of action, making them complementary approaches for the management of acid-peptic disorders [8-12,17,19]

COMPARATIVE MECHANISM OF ANTIULCER ACTION

Both Avipattikar churna and sutshekhar rasa act through various mechanisms that help to treat ulcers. Avipattikar churna helps to improve digestion through Deepana and Pachana, reduce oxidative stress, protect the gastric mucosa, and reduce Pitta via a mild laxative effect. On the other hand, sutshekhar rasa alleviates irritation in the stomach by Pitta Shamana and protecting the mucosa. Moreover, being a major ingredient in this formulation, Shankha bhasma is believed to help neutralize the excess acidity in the stomach. Thus, both these drugs help to balance the Pitta dosha and heal the ulcerated region in the stomach. [31-38]

COMPARATIVE EXPERIMENTAL EVIDENCE

Experimental studies are essential to verify the traditional claims about the pharmacological effects of the selected Ayurvedic preparations. A number of experiments were conducted to prove the ulcer-healing and ulcer-protective properties of Avipattikar Churna. Meanwhile, the number of experimental studies conducted for Sutshekhar Rasa seems limited. Below are the results of the available experiments, conducted to evaluate the pharmacological properties of Ayurvedic preparations. [8-12,17,19,39,40]

COMPARATIVE SAFETY AND TOXICITY PROFILE

The safety and toxicity of Ayurvedic preparations play a crucial role in establishing their clinical efficacy and scope of application. The reviewed research suggests that Avipattikar Churna, which is a polyherbal preparation, is safe when used at recommended doses. Sutshekhar Rasa, in its turn, is considered to be free from adverse effects if prepared properly and only by authorized physicians, which, however, has been subject to limited investigations conducted to date. Therefore, while both formulations are widely used in the management of Amlapitta, further well-designed toxicological and long-term safety studies are warranted, particularly for Sutshekhar Rasa. [25-30]