Therapeutic Evaluation of Majoon e Azaraqi in the Management of Rheumatoid Arthritis: A Case Study

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Nusrath Thasneem¹ , Mushtaq Ahmed C² , Mubasheera begum¹ , S.Mussadiq Ahmed¹

¹Department of Moalajat, Government Unani Medical College, Chennai, Tamil Nadu 600106, India

²Government Unani medical college, Chennai, Tamil Nadu 600106, India

Corresponding Author Email: nusraththasneem@gmail.com

DOI : https://doi.org/10.51470/APR.2025.04.02.13

Abstract

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INTRODUCTION

Traditional Unani medicine encompasses arthritic conditions within the comprehensive terminology of Waja al-Mafaṣil, derived from Arabic nomenclature signifying “articular pain.” The clinical manifestations of this condition demonstrate remarkable similarity to rheumatoid arthritis as recognized in contemporary medical practice. The etymological breakdown reveals “waja” denoting pain and “mafasil” referring to articulations, thus providing a literal interpretation of “joint pain.” Historical documentation of this pathological state spans ancient Egyptian, Unani, and Roman medical literature.

The renowned physician Ibn Sina (Avicenna) characterized Waja al-Mafaṣil as a pathological state featuring pain, accompanied by varying degrees of stiffness, affecting single or multiple joints. This condition manifests as Hudar (Rheumatoid arthritis), representing a chronic systemic inflammatory process predominantly targeting the smaller articulations of hands and feet in bilateral distribution. The pathophysiology encompasses deforming polyarthritis, synovial inflammation affecting joints and tendon sheaths, progressive articular cartilage deterioration, juxta-articular bone erosion, osteopenia development, and the presence of IgM rheumatoid factor along with anti-cyclic citrullinated protein antibodies (ACPAs) in the majority of patients. Furthermore, rheumatoid arthritis frequently presents with diverse extra-articular complications.

The global prevalence of rheumatoid arthritis approximates 1% of the population, while Indian epidemiological data indicates prevalence rates ranging from 0.5% to 0.75%. Gender distribution demonstrates female predominance with a 3:1 ratio. Within Unani medical theory, rheumatoid arthritis results from the accumulation of ruṭūbat ghariba (pathological substances) within joint spaces. The predominant pathological substance identified is Ṣafrā’-e-Balghamī (phlegmatic bile), succeeded by Balgham-e-Khām (raw phlegm), Dam (sanguine humor), Ṣafrā (yellow bile), and infrequently Sawdā (black bile) [2].

Clinical presentation encompasses pain, edema, tenderness, and morning rigidity primarily affecting hand, foot, knee, and ankle articulations. When the causative agent (maddah) infiltrates joint spaces, inadequate absorptive capacity (Qawwat-e-Jazibah) prevents proper assimilation, while diminished expulsive power (Quawwat-e-dafia) impedes elimination, resulting in substance retention within joints [3]. Prolonged retention increases viscosity (Ghilazat) and viscidity (Lazoojat), leading to hardening processes, joint ankylosis initiation (Tahajjur-e-mafasil), and progression toward incurability [4].

Contemporary rheumatoid arthritis management incorporates nonsteroidal anti-inflammatory medications (NSAIDs), disease-modifying anti-rheumatic drugs (DMARDs), tumor necrosis factor-α inhibitors, and corticosteroids, all associated with significant adverse effects during extended administration. Given the chronic nature requiring prolonged treatment, identifying safe and effective therapeutic alternatives becomes paramount. Unani medicine encompasses extensive pharmacological resources, including individual and compound preparations historically employed by ancient practitioners for Waja’al-Mafasil management. However, these therapeutic approaches require rigorous scientific validation to establish safety and efficacy profiles. Consequently, this investigation was designed to evaluate the safety and therapeutic effectiveness of Majoon e Azaraqi, a polyherbal Unani formulation, in treating Waja’al-Mafasil (rheumatoid arthritis).

Unani Concept of Waja al-Mafasil

Ibn-e-Sina characterizes Waja’al-Mafasil as a clinical entity distinguished by pain and stiffness affecting one or multiple joints, attributed to ratubat-e-ghariba (foreign humor) accumulation within joint structures [6]. Zakariya Razi conceptualizes “Waja al-Mafasil” as a condition manifesting through recurrent or paroxysmal episodes resulting from excessive fluid accumulation within joint cavities. His classification system groups gout, Irq-un-nisa (sciatica), and Waja’al-Mafasil within the same disease category [7]. Ismail Jurjani defines Waja’al-Mafasil as the consequence of morbid matter accumulation within joint organs, precipitating discomfort and inflammatory responses [8]. Akbar Arzani describes Waja’al-Mafasil as discomfort affecting hand and foot joints accompanied by inflammation, noting that pain may manifest with or without concurrent joint inflammation [9].

Samar Qandi provides an expanded definition encompassing pain and inflammation within joint-surrounding tissues, including synovium, ligaments, tendons, musculature, and muscular covering membranes. The pathological process occasionally affects organ-encasing membranes such as cardiac and pulmonary structures, resulting in inflammation and erythematous appearance. Mandibular, spinal, and auditory ossicle involvement may occur, creating diagnostic complexity [10,11]. Historical medical authorities including Ibn Rushd (1188 AD) in Kitab-ul-Kulliyat [13], Rabban Tabri (898 AD) in Firdaws al-Hikma fi’l Tibb [14], and Majoosi (930 AD) in Kamil al-Sana’a al-Tibbiyya [15] documented this condition in their respective treatises.

2. Materials and methods

This investigation employed a single-patient, open-label clinical methodology to evaluate Majoon-e-Azaraqi efficacy in managing Hudar (Rheumatoid Arthritis) according to ACR/EULAR 2010 classification criteria. A 32-year-old female patient with confirmed rheumatoid arthritis diagnosis was recruited from the Unani Outpatient Department, Aringar Anna Government Hospital of Indian Medicine & Homoeopathy, Chennai, Tamil Nadu. Primary complaints included bilateral interphalangeal joint pain and stiffness with associated finger movement difficulties, predominantly morning stiffness.

The patient reported significant impact on social and professional functioning, with daily activities becoming challenging due to pain and stiffness symptoms. This resulted in emotional distress, frustration, and feelings of helplessness. While anxiety and depression were not prominently expressed, ongoing symptoms substantially reduced quality of life. Family history revealed no relevant similar conditions. Physical examination demonstrated unrestricted flexion and extension of bilateral interphalangeal joints. Radiographic evaluation of both hands and wrist joints (anterior-posterior and lateral views) remained within normal parameters. Laboratory findings revealed positive ASO titer, supporting rheumatoid arthritis diagnosis.

Inclusion criteria required symptom persistence for minimum 6 months, while exclusion criteria eliminated patients with comorbidities including hypertension, diabetes, or severe joint deformity. Ethical approval was secured, and informed consent obtained prior to participation, ensuring compliance with Declaration of Helsinki and ICMR guidelines.

The intervention protocol involved Majoon-e-Azaraqi administration (5g twice daily with lukewarm water) for 8 weeks. The formulation was prepared according to pharmacopoeial guidelines at Anna Hospital Pharmacy, comprising polyherbal ingredients with established anti-inflammatory, analgesic, and antioxidant properties.

2.1 Drug preparation and mode administration[13]

The raw drugs, namely Azaraqi Mudabbar, Berg-e-Gaozaban, Ustukhuddus, Kateera, Narjeel, Maghz-e-Chilghoza, Dana Heel Khurd, Zarambad, Shaqaq-ul-Misri, Sandal Safaid, Aamla, Halela Siyah, Ood Hindi, Qaranfal, and Qand Safaid, were procured from the local market. Ingredients 1 to 4 and 7 to 14 were cleaned, dried, powdered, and sieved through an 80 mesh, and kept separately. Ingredients 5 and 6 were coarsely powdered and sieved through a 60 mesh. Ingredient 15 was dissolved in 750 ml of water on slow heat, and at the boiling stage, 0.1% citric acid was added and mixed thoroughly. The mixture was boiled, and 0.1% sodium benzoate was added at a 72% consistency of quiwam and mixed well. The quiwam was then corrected to 77% consistency. The vessel was removed from the fire, and while hot, the powders of ingredients 1 to 14 were added and mixed thoroughly to form a homogenous product. Finally, the mixture was cooled to room temperature and packed in tightly closed containers to protect it from light and moisture. The medicine was prepared in the ANNA HOSPITAL PHARMACY according to the guidelines of the Anna Hospital Pharmacopoeia.

3. Analysis:The patient was assessed at baseline and then again on the 8th week, after completing the treatment. The assessment was conducted using subjective parameters such as pain, tenderness, and joint stiffness based on the Visual Analog Scale (VAS), as well as objective parameters including the DAS 28 Questionnaire to evaluate the improvement in quality of life. Inflammatory markers, such as ASO, CRP, and RA Factor, were also measured. A paired t-test was used for the pre- and post-treatment comparison for the subjective parameters

Mean (Baseline): 7.00;Mean (Post Treatment): 2.33

Standard Deviation (Baseline): 1.00;Standard Deviation (Post Treatment): 0.58

p-value (Paired t-test): 0.0051

weeks of medication, the pain level was reassessed, and the VAS score dropped to around 2, indicating a significant reduction in pain. Additionally, objective parameters, including the DAS28 score, showed notable improvement, decreasing from 5 at baseline to 2 after 8 weeks. There was also a marked improvement in inflammatory markers such as CRP, ASO titer, and RA factor. These therapeutic interventions led to significant improvements in both subjective and objective parameters. A paired t-test was performed on the VAS scores for morning stiffness, joint pain, and tenderness to assess the statistical significance of symptom reduction. The results indicated a statistically significant reduction in symptoms, with a p-value of 0.0051 (p<0.05), confirming the efficacy of Majoon-e-Azaraqi in managing rheumatoid arthritis symptoms. These findings align with the care guidelines for the management of rheumatoid arthritis, demonstrating the effectiveness of this therapeutic intervention.See fig :3.1,3.2

5.Discussion

This case report highlights the potential of Unani formulations, particularly Majoon-e-Azaraqi, in managing rheumatoid arthritis (RA). The patient showed significant improvements across both subjective and objective parameters, including a substantial reduction in pain (as measured by the VAS score), joint stiffness, and key inflammatory markers such as CRP, ASO titer, and RA factor. These improvements suggest that Majoon-e-Azaraqi may possess valuable anti-inflammatory properties that could complement conventional RA treatments and help manage symptoms more effectively. However, several diagnostic challenges arose during the study. One primary difficulty was differentiating RA from other inflammatory joint disorders like osteoarthritis or psoriatic arthritis, given the overlap in clinical presentations. Additionally, interpreting blood tests, particularly the positive ASO titer, proved challenging since similar results can be found in other autoimmune conditions. The study’s limitations include the lack of a control group and a short duration of treatment, which hinder the ability to draw definitive conclusions about the long-term efficacy of Majoon-e-Azaraqi. These factors highlight the need for further high-quality research, such as randomized controlled trials, to more thoroughly evaluate the therapeutic potential of this Unani formulation. Despite these limitations, the case supports the possibility of integrating traditional remedies like Majoon-e-Azaraqi into modern medical care, provided there is sufficient evidence to support their safety and efficacy. Furthermore, the case emphasizes the importance of accurate early diagnosis in RA to differentiate it from similar conditions and ensure effective treatment. The favorable tolerability of Majoon-e-Azaraqi, along with the patient’s good adherence to the treatment regimen, further underscores its potential as a complementary approach to managing RA symptoms.

Patient Perspective:The patient has reported notable improvements in managing her osteoarthritis since initiating treatment with Majoon e Azaraqi. She describes a reduction in pain and stiffness, particularly in the interphalangeal joint, which has facilitated increased mobility and the ability to perform daily activities with less discomfort. Additionally, the patient mentions improved sleep quality, as joint pain no longer interrupts her rest. While the pain has not been completely alleviated, it is now more manageable, allowing for greater physical activity and engagement in light exercises and physical therapy, which may further contribute to her improvement. The patient’s feedback indicates a positive impact on her overall mobility and quality of life, suggesting potential therapeutic benefits for osteoarthritis management.

Informed Consent Statement:Informed consent as obtained from the subject.

Ethical compliance statement: The authors confirmed that patients provided written informed consent for the publication of the literature.

Funding sources:No specific funding was received for this work.

Data availability statement:The data are available from the corresponding author on reasonable request.

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