Safety and Efficacy of an Ayurvedic Formulation Cystone in Management of Ureteric Calculi: A Prospective Randomized Placebo Controlled Study

Problem statement: Medical management of urolithiasis is still a chal lenge for modern medical practice. In the present study, Cystone tab le , an Ayurvedic formulation claimed to be useful in urolithiasis was evaluated for its safety and ef ficacy in reduction or expulsion of ureteric calcul i and to assess the role of Cystone in relieving the clin ical symptoms. Approach: This was a prospective randomized, double blind placebo-controlled trial a mongst 52 patients with upper urinary tract calculi of 5-10 mm diameter. Patients were evaluated by pla in abdominal film of the Kidneys, Ureter and Bladder (KUB) plus an ultrasound examination, for 6 months. Patients were equally divided into active treatment or placebo. The patients were advised to take Cystone or placebo in a dose of one tablet, thrice daily for 6 months. Patients kept a record o f number of pain episodes; severity of pain was assessed by Visual Analogue Scale (VAS). In additio n, other parameters such as fever, low backache and decrease in frequency of urine were evaluated t o assess the relief of clinical symptoms. Urinary microscopy and hamatological parameters were also e valuated. Results: In active medication group, there was a significant reduction in the size of th e calculi while there was an increase in the placeb o arm. There was significant lower VAS score in the a ctive medication arm as compared to placebo. On urine analysis, significant reduction in microscopi c hematuria, pus cells (pyuria), bacteruia and crystalline sediments was seen. Significant disappe rance of the calculi by both X-ray abdomen and ultrasonography and a significant reduction in the size of the stone was seen with Cystone treatment. There was no improvement in relief of clinical symp toms or investigations in the placebo treated subjects. Conclusion: This study suggested that the Ayurvedic formulatio n Cystone tablet had a therapeutic promise in the management of ureteric c al uli. It probably helped in reducing the size of the calculi and facilitates in its passage and sign ificantly relieves the symptoms with improvement in urine parameters. This formulation was well tolerat d.


INTRODUCTION
Humankind is known to be suffering from urinary stone disease, which was first noticed by Egyptian mummies dated to 4800 BCE 1 . Hippocrates in the 4th century BCE noted renal stones together with a renal abscess and wrote in the Hippocratic oath "I will not cut the stone" (Clendening, 1960). Urolithiasis in its different forms is a frequently encountered urological condition. For many years it has been at the forefront of urology. This situation might have changed with the advent of new, less invasive approaches to the management of urinary calculi. Nevertheless, urinary stones continue to occupy an important place in everyday urological practice. Currently urinary stones affect 10-12% of the population with a peak incidence at 20-40 years of age (Wasserstein, 1998). It is one of the most common and painful urologic disorder of the urinary tract that affects more than 3 million people every year alone in the United States (Hollingsworth et al., 2006). The lifetime risk of developing urolithiasis ranges between 5 and 12% (Alok et al., 2008) and significantly affects the economy and public health as it has a high rate of recurrence (Hiatt et al., 1982).
Risk factors for developing urolithiasis include age, sex, diet, geographic location, genetic predisposition and urinary composition. Apart from these, the anatomy of the upper and the lower tract might be contributing factor in predisposing an individual to urinary tract infection or stasis (Gupta and Kesarwani, 2002). Small urinary calculi pass out of the body without any clinical intervention (Miller and Kane, 1999). In several studies, it has been reported that spontaneous passage rates of urinary stones ranges between 70-98% for small (≤5 mm) distal ureteric calculi (Healy and Ogan, 2005). However size and location of the calculi play an important role in predicting spontaneous passage. Typical symptoms of acute renal colic are intermittent colicky flank pain that may radiate to the lower abdomen or groin, often associated with nausea and vomiting (Eskelinen et al., 1998). Lower urinary tract symptoms such as dysuria, urgency and frequency may occur as the stone enters the ureter. Large calculi associated with unbearable pain can be treated with ureteroscopy, extracorporeal shock wave lithotripsy, percutaneous nephrostomy and surgery. Calcium channel blockers and adrenergic alpha antagonists and steroids are effective in enhancing the passage of urinary calculi. Phytotherapy with medicinal plants is widely used worldwide as an alternative primary healthcare. Regarding the treatment of urinary stone disease, several medicinal plants are available (Nirdnoy and Muangman, 1991;Yasui et al., 1999;Selvam et al., 2001;Premgamone et al., 2001;Freitas et al., 2002;Atmani et al., 2004). Since the plants are claimed to be non-toxic, low-cost, available in rural areas and culturally acceptable, their effectiveness in the treatment of urinary stones has been widely studied. Herbal medicines have been used to help in urolithiasis through anti-inflammatory, diuretic, litholytic, antimicrobial and antispasmodic actions, though many of these properties are speculative. Cystone tablets, one such an Ayurvedic formulation and has been claimed for its safety and efficacy in Urolithiasis. The principal herbs of Cystone tablets (Table 1) have undergone extensive studies and geographical source and harvest time for each of the herbal ingredients have been recorded. Good Agricultural and Collection Practice (GACP) was followed during the collection and manufacture of this Ayuurvedic formulation (Sing et al., 2007. Botanical identification and an Ayurvedic criteria for desired quality were in accordance with the guidelines of Pharmacopoeial Standards of an Ayurvedic formulations (Fong, 2002) and were carried out by a qualified chemist approved by the Food and Drug Administration. This formulation has been approved by regulatory authorities in India as an Ayurvedic formulation and is available for clinical practice for the past sixty years. This study was aimed to evaluate the efficacy and safety of Cystone tablets in subjects with urolithiasis.  (Puri et al., 2009). Allocation was concealed. The sample size of 52, with 26 in each arm was calculated to have a power to detect a 25% reduction with urinary stones at 95% confidence limit.
Inclusion and exclusion criteria: Patients of either sex aged 18-65 years presenting clinically with characteristic loin pain, vomiting, fever and radiological or ultrasonographically diagnosed with ureteric calculi measuring between 5-10 mm in size and willing to sign the informed consent form and comply with the study procedures were included in the study. Those with larger urinary calculi, renal and or hepatic pathology and any systemic disorder requiring other medication or surgery were excluded from the study. Pregnant and lactating women were not included in the study.

Study procedure:
This study was carried out in 52 consecutive eligible patients out of 81 patients who attended the Urology Clinic at Safdarjung Hospital, New Delhi, India. The study protocol, Case Report Forms (CRF), regulatory clearance documents, product related information and informed consent forms (in English and Hindi) were approved by the institutional ethics committee. The patients were informed about the study drug, its effects, duration of the trial and overall plan of the study and were included in the clinical study only after written informed consent was obtained from each of them. They were free to withdraw from the study if they so desired. Patients ate their ad libitum diets. Detailed clinical history was noted by interviewing the patients. Thorough clinical examination and symptomatic evaluation was carried out and the details were noted in the CRF. Urolithiasis was determined clinically, the diagnosis was confirmed by plain X-Ray of the abdomen followed by ultrasonography. The X-Ray KUB and ultrasonography was used to calculate the surface area of each stone based on length and width. Largest diameter of a stone was considered instead of the surface area in ultrasonography evaluation. The cumulative diameter was calculated for subjects with multiple calculi. Patients were advised to take the Ayurvedic formulation Cystone or an identical placebo in a dose of one tablet thrice daily orally for six months. All patients were asked to maintain a record of number of pain episodes, while severity of pain was assessed on a visual analogue scale (Hollingsworth et al., 2006). Patients underwent clinical, hematological and radiological evaluation on entry, at 3 and 6 months. The clinical symptoms like fever and low backache were scored using numerical scale. They were allowed Diclofenac 50 mg tablet in case of severe abdominal pain.

Primary and secondary outcome measures:
The predefined primary outcome measures were the effect on change in the number and size, spontaneous passage of stone and symptomatic relief. The predefined secondary outcome was incidence of adverse effects and patient compliance.
Adverse events: All adverse events reported or observed by patients were recorded with information about severity, date of onset, duration and action taken regarding the study drug. Relation of adverse events to study medication were predefined as "Unrelated" (a reaction that does not follow a reasonable temporal sequence from the administration of the drug), "Possible" (follows a known response pattern to the suspected drug, but could have been produced by the patient's clinical state or other modes of therapy administered to the patient) and "Probable" (follows a known response pattern to the suspected drug that could not be reasonably explained by the known characteristics of the patient's clinical state).
Patients were allowed to voluntarily withdraw from the study, if they had experienced serious discomfort during the study or sustained serious clinical events requiring specific treatment. For patients withdrawing from the study, efforts were made to ascertain the reason for dropout. Non-compliance (defined as failure to take less than 80% of the medication) was not regarded as treatment failure and reasons for noncompliance were noted.
Statistical analysis: Statistical analysis was carried out using Fisher's Exact Test for presence or absence of various signs and symptoms. Repeated measures of ANOVA followed by Dunnett's Multiple Comparison Posthoc Test were used for analysis of haematological parameters. Pyuria was analyzed by repeated measures of ANOVA using Friedman test followed by Dunnett's Multiple Comparison Posthoc Test. Calculi size before and after treatment was analyzed using Paired Student's 't' test. Values are expressed as mean ± SD for haematological parameters, pyuria and calculi size and remaining parameters were evaluated by the incidence of symptoms. The minimum level of significance was fixed at p<0.05. Statistical analysis was carried out using GraphPad Prism Version 4.03 for Windows, GraphPad Prism Software, San Diego California USA.

RESULTS
The demographic data of the patients on entry (Table 2) indicated that thirty eight males and fourteen female patients with a mean age of 34.73±10.09 years were included in the study. Out of the 52 subjects, 26 subjects each received either Cystone tablets or placebo in a random fashion. With Cystone treatment, a significant (p<0.0001) symptomatic relief from intermittent abdominal pain (58%), fever (92%), low backache (54%) was observed (Table 3).
There was also an improvement in the frequency and flow of urine though it was not significant. Urine analysis, indicated significant (p<0.0001) improvement in microscopic hematuria, pus cells, bacteriruria and crystalline sediments ( Table 4).
Disappearance of the calculi as seen by ultrasonography was noticed in 13 out of 26 patients (50%) treated with Cystone tablets (p<0.0001) and a decrease in the size of the stone in remaining subjects. In patients treated with placebo out of 26 patients, there was disappearance of stone in 2 patients. Disappearance of the calculi by plain X-ray abdomen and pelvis was seen in 15 patients out of 26 patients (58%) treated with Cystone tablets (p<0.0001) there was decrease in the size of the stone in another 11 subjects. In patients treated with placebo out of 26 patients, there was disappearance of stone in 2 patients (Table 5).

DISCUSSION
There are a number of options for treatment of urinary calculi, including surgery, endoscopic procedures such as ureteroscopy, percutaneous nephrolithiotomy and extracorporeal shockwave lithotripsy (Heilberg and Schor, 2006). Patients invariably prefer a medical therapy for the advantage of convenience. Medications like calcium channel blockers, alpha-adrenergic blockers, steroids are used but adverse effects compromise their long-term consumption. On the other hand, some herbal remedies have been used to treat urinary stone disease, although scientific principles have been lacking. With the understanding of many pathophysiological features underlying urinary stone disease and the mechanism of herbal remedies that can have a role in the formation and treatment of urinary stones; phytotherapy might be an alternative treatment with an effective, safe and acceptable options. Although some oral medications have positive effects, they are not effective in all patients. Oral citrate is one of the most widely used medical therapies for preventing urinary stone disease (Serhat and Kupeli, 2006). However, this drug is not tolerated by all patients and some patients are still active stone formers during this therapy (Mattle and Hess, 2005). Due to the adverse effects of these drugs, alternative treatment modalities composed of herbal remedies have been the mainstay of medical therapy for thousands of years, especially in Eastern civilizations (Serhat and Kupeli, 2006). Use of medicinal plants as a source of relief and cure from various illness is as old as humankind itself. Even today, medicinal plants provide a cheap source of drugs for majority of world's population. Plants have provided and will continue to provide not only directly usable drugs, but also a great variety of chemical compounds that can be used as starting points for the synthesis of new drugs with improved pharmacological properties (Potterat and Hostettmann, 1995). World Health Organization has also emphasized development and utilization of herbal drugs and traditional medicines for the benefit of the world population, in terms of cost effectiveness and side effects of the drugs. The organization has also estimated that about 80% of the population living in the developing countries relies on traditional medicine for their healthcare needs (World Health Organization, 2002).
Cystone is an Ayurvedic formulation, designed and developed for the management of urolithiasis or renal calculi. This product came into existence in 1943 and since then this product has been in use all over the world for the management of urolithiasis and UTI.
Herbs like Didymocarpus pedicellata has been shown to have diuretic activity (Chopra et al., 1996a). Another plant, Saxifraga ligulata, is reported to have active principles like afzelechin and bergenin. Afzelechin and bergenin are tannins and possess astringent properties, which make them effective antimicrobial agents. Bergenin is a known diuretic and is helpful in dissolving kidney stones (Asolkar et al., 1992;Chopra et al., 1996b). The roots of Rubia cordifolia contain ruberythic acid, which has been proved to dissolve oxalate stones present in the urinary tract, thereby facilitating their expulsion without recourse to surgery (Basu and Hazra, 2006;Tripathi and Sharma, 1999;Jisha and Nair, 2008). It also possesses astringent, antibacterial and anti-inflammatory actions. The oil from the roots of Cyperus scariosus has been found to exhibit anti-inflammatory properties (Khare, 2004;Chopra et al., 1996c). Studies conducted on the extracts of Cyperus scariosus were found to have potent antioxidant activity. Achyranthes aspera has potent anti-inflammatory, astringent, demulcent and diuretic activity (Chopra et al., 1996d). Onosma bracteatum is known to have diuretic action. It regulates urine output, acts as a demulcent and provides soothing action. It is useful in bladder irritation and is a spasmolytic (Khare, 2007). Hajrul Yahood bhasma is useful as a diuretic and a lithotropic. It is given in retention of urine and in other diseases of the urinary tract. Shilajeet (purified) treats urinary disorders due to its tonic activity (Agarwal et al., 2007). It is probable that these ingredients may be producing an additive activity to bring about relief in Urolithiasis. Several of these herbs contain saponins which have antiuroliathiatic effect.

CONCLUSION
The present study indicates that Cystone tablet is an effective and safe alternate in the management of Urolithiasis. It brings about significant symptomatic relief and helps in expulsion of stones or reducing the size of the renal stones. No clinically significant adverse reactions were reported or observed during the study period. A further study in a larger population will be required to confirm the evidence seen in the present clinical study.

ACKNOWLEDGEMENT
Thanks to The Himalaya Drug Company for supply of study medications and facilities.