Efficacy and safety of integrative therapy of Drakshavaleha with oral iron folic acid supplements in management of mild to moderate iron deficiency anaemia in women of reproductive age group- A protocol for a parallel group randomized controlled trial

Abstract

Background

Adding Drakshavaleha to iron-folic acid (IFA) supplementation could lead to a significant increase in hemoglobin (Hb) levels compared to IFA alone due to its bioavailability-enhancing property. This paper presents a protocol for the randomized controlled trial (RCT) assessing the efficacy and safety of integrating Drakshavaleha with IFA supplementation in improving hemoglobin levels among women aged 18-49 years with mild to moderate iron-deficiency anaemia.

Methods

This parallel-group, open-label, community-based randomized controlled trial will include women aged 18 to 49 years with mild (Hb 11-11.9 g/dL) to moderate (Hb 8-10.9 g/dL) iron deficiency anaemia. Consecutive participants meeting the inclusion/exclusion criteria will be enrolled after providing written informed consent and randomly assigned to one of two groups in a 1:1 ratio using block randomization. The control group will receive 200 mg of ferrous sulphate and 0.5 mg of folic acid orally, twice daily after food for 3 months. The intervention group will receive 6 g of Drakshavaleha orally, twice daily before food, in addition to the same IFA dosage as the control group. Participants will be followed up monthly at 1, 2 and 3 months. At all follow-up visits, CBC and iron profiles will be done whereas serum creatinine, serum bilirubin, serum glutamic pyruvic aminotransferase (SGPT), and HbA1C will be done at 3 months.

Conclusion

This protocol outlines the RCT to assess the efficacy and safety of integrating Drakshavaleha with IFA supplements and explore Drakshavaleha's role in enhancing assimilation of oral iron from supplements and nutrition.

Trial registration number

The trial is registered in Clinical Trials Registry - India (CTRI) under registration number CTRI/2024/05/067169.

1. Introduction

Anaemia is a major public health concern in India. According to National Health Family Survey 5 (2019-21), 57.2% women of reproductive age group (15 to 49 years) suffer from anaemia in India [1]. To reduce the burden of anaemia in the country, the Government of India launched Anemia Mukt Bharat Programme in 2018 to reduce the prevalence of anaemia by 3 percentage points per year among children, adolescents, and women in the reproductive age group (15–49 years), between the year 2018 and 2022 [2]. A targeted prevalence reduction of anaemia in women of the reproductive age group was set from 57% (2016) to 35% (2022) under this program [3]. However, as per the NFHS 4 to NHFS-5 results, the prevalence of anaemia has not reduced during the last 5 years. The major issue with iron and folic acid (IFA) supplements is poor compliance due to forgetfulness and intolerable gastrointestinal (GI) side effects [4,5]. Iron deficiency and iron load both can cause oxidative stress which in turn causes intestinal mucosal damage due to inflammation. Thus, iron absorption is affected in most of the anaemic patients which may reduce the impact of oral iron supplementation and may cause gastrointestinal problems [6]. The addition of Vitamin C to IFA helps enhance the absorption of iron by keeping it in a reduced ferrous form. However, it does not address the issue of gastrointestinal side effects. In a large single-center, open-label, equivalence trial, oral iron supplements alone were found equivalent to oral iron supplements plus vitamin C in improving hemoglobin recovery and iron absorption in anaemic patients [7]. Despite of wide promotion of IFA amongst beneficiaries, the burden of anaemia remains the same which suggests the need for additional measures to improve nutrition, compliance, and/or additional use of alternative systems of medicine that can address the issue of assimilation of iron and its GI side effects.

Drakshavaleha is an ayurvedic formulation that serves as both a nutritional supplement and a recognized agni (digestive fire)-enhancing rasayana (rejuvenator) in ayurveda. It comprises a diverse array of ingredients, including Amalaki (Emblica officinalis Gaertn.) and Yashtimadhu (Glycyrrhiza glabra L.), which contribute to the process of erythropoiesis [8,9]. Draksha (Vitis vinifera L.), on the other hand, acts as a rakta prasadaka (blood-nourishing) agent, facilitating improved blood circulation within the body's tissues [10]. Yashtimadhu (Glycyrrhiza glabra L.), tvakshiri (Bambusa arundinacea (Retz.) Willd.), and madhu (honey), are known for their anti-ulcerative/anti-inflammatory properties, which sustain optimal gastric function and are essential for iron absorption [[11], [12], [13]]. Pippali (Piper longum L.), possessing anti-helminthic qualities, further acts as a bio-availability enhancer [14]. Sugar containing iron as well as absorption-enhancing elements such as sulphur, fructose, and copper presents itself as a promising dietary supplement for addressing iron deficiency anaemia (IDA). Given its composition and inherent properties, this formulation is classified as Balya (strength promoting) and Brumhana (nourisher), effectively tackling nutritional concerns in cases of IDA. Drakshavaleha has the potential to enhance iron absorption and, by improving digestion and mitigate the inflammatory reactions that iron might trigger in the gastrointestinal tract. Consequently, the addition of Drakshavaleha to IFA supplementation might yield a more substantial increase in Hb levels compared to IFA alone. This combined approach could also help to alleviate potential GI side effects associated with iron supplementation. The objectives of the present study are to:

• •To determine the efficacy of integrative therapy of Drakshavaleha with IFA supplementation as compared to IFA alone in improving hemoglobin levels among mild to moderate iron-deficiency anaemia among reproductive age group women of 18-49 years.
• •To determine changes in red cell indices (RBC count, MCV, MCH, MCHC) and iron profile, (serum iron, total iron binding capacity, serum ferritin, transferrin saturation) between study groups.
• •To compare the change in quality-of-life score at the end of 90 days of treatment from baseline between the study groups using Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) scale.
• •To estimate the frequency of adverse reactions in study population and compare them between study groups.

2. Materials and methods

The present study is a parallel group, open-label, community-based randomized controlled trial involving women of reproductive age group (18 to 49 years) with mild (Hb 11-11.9) to moderate (Hb 8 to 10.9 g/dL) iron deficiency anaemia. The criteria for enrollment in the trial will be decided based on the following inclusion/exclusion criteria.

2.1. Inclusion criteria

• •Women of reproductive age group (18 to 49 years) with mild (Hb 11-11.9) to moderate (Hb 8 to 10.9 g/dL) anaemia.
• •Serum ferritin <30 mcg/dL.
• •Should consent to receive any type of intervention before randomization.
• •Not participating in any other research study.

2.2. Exclusion criteria

• •Pregnant and lactating women.
• •Known cases of anaemia due to other causes (Sickle cell anaemia; Thalassemia minor).
• •Those who are already consuming IFA >14 days.
• •HbA1C > 6.5%.
• •Known diabetics on regular medicines.
• •Known allergy to iron and ingredients of Drakshavaleha.
• •Participant with known chronic kidney and liver disease.
• •Any other condition in the advice of the treating doctor that is putting the participant at risk due to study participation.

Eligible participants will be randomized into either the control or intervention group. The control group participants will receive ferrous sulphate 200 mg + folic acid 0.5 mg twice daily orally after food for 3 months. The intervention group participants will receive Drakshavaleha [15] 6 gm twice daily before food in addition to IFA therapeutic dosage (ferrous sulphate 200 mg + folic acid 0.5 mg twice daily orally after food) for 3 months. Although Drakshavaleha is traditionally recommended after food to avoid gastric irritation, when used concomitantly with IFA tablets to avoid simultaneous intake and more gastrointestinal irritation, it will be given before food. Additionally, the presence of ingredients such as Pippali and Shunthi, which are considered bioavailability enhancers, may support digestive function and facilitate better iron assimilation when present in the gut before iron administration. IFA tablets were administered after food to minimize gastrointestinal side effects and improve participant compliance [16]. IFA tablets and Drakshavaleha have been procured from the good manufacturing practice certified manufacturer (IFA tablets from GDM Nutraceuticals LLP, Surat, and Drakshavaleha from KLE Society's Ayurved Pharmacy, Belagavi). A certificate of analysis for both drugs will be obtained.

2.3. Study procedures

The present study will be conducted in the villages of selected primary health centers (PHCs) of Belagavi district of Karnataka. The study will be of 3 months duration, and follow-up will be done monthly at 1, 2, and 3 months.

2.4. Selection of study site

2-3 PHCs will be selected in consultation with the District Health Officer (DHO) where burden of anaemia is high. Permission for conducting the study will be taken from the DHO. Medical officers of selected PHCs will be approached for study briefing and rapport building. Villages will be selected for screening the participants in consultations with respective medical officers where burden of anaemia is high. Peripheral health workers will be involved in implementation of project activities along with the trained project staff.

2.5. Screening and participant recruitment

Women of the reproductive age group (18 to 49 years) will be invited to Anganwadi centers with the help of peripheral health workers and will be subjected to Hb screening by Hemocue 301. Women with an Hb level of 8 to 11.9 g/dL will be invited for the study and they will be informed in detail about the study. After obtaining written informed consent, detailed clinical and drug history will be taken. Blood will be collected for evaluation of inclusion/exclusion criteria. After getting the blood reports, project staff will visit the houses of eligible participants and will provide intervention according to their randomization. At the baseline visit, the participant's weight will be measured. Quality of life will be assessed by the Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) scale (Version 4). The FACIT-F scale contains 13 items that help in measuring health-related QoL in participants with chronic illnesses, including anaemia. It is easy to administer, and it covers physical, social, emotional and functional wellbeing. The score ranges from 0 to 52. Jatharagni (Metabolic factors located in the digestive tract) will be assessed using a standard Ayurveda questionnaire [17].

2.6. Randomization

All consecutive participants fulfilling inclusion/exclusion criteria will be enrolled for the study after obtaining written informed consent. Participants will be randomly allocated to two groups, i.e., control and intervention in the ratio of 1:1 with block randomization (block size = 4, number of blocks = 53) by online generated random number sequence using Sealed Envelope. A sequentially numbered opaque sealed cover will be prepared which will contain the randomization codes. The investigator will open the cover at the baseline visit of a particular participant as per the randomization number. The randomization process will be done by the study coordinator, who will not be involved in participant recruitment. The participants will receive either of the treatments as per the randomization code.

The study team will educate the participant about the treatment and maintain compliance with the study treatment. Participants will be followed up monthly at 1 (±3 days), 2 (±3 days), and 3 (±4 days) months. The drug will be distributed at baseline, 1 and 2 months. At all follow-up visits, CBC and iron profiles will be done whereas serum creatinine, serum bilirubin, serum glutamic pyruvic aminotransferase (SGPT), and HbA1C will be done at 3 months. All investigations will be performed at NABL accredited laboratory. At all follow-up visits, drug compliance and adverse events will be assessed. At the end of 3 months, QoL and Jatharagni assessment will be done. The study activities as per timeline are listed in Table 1.

Table 1.

Schedule of events in study protocol as per follow-up timelines.

Activity	Screening	Baseline	Day 30 ± 3	Day 60 ± 3	Day 90 ± 4
Hb by Hemocue 301	X	-	-	-	-
Written Informed Consent	X	-	-	-	-
Inclusion/Exclusion Criteria	X	X	-	-	-
Clinical History	X	X	X	X	X
Drug History	X	X	X	X	X
Jatharagni Shakti and QoL assessment	-	X	-	-	X
Weight	-	X	X	X	X
Randomization	-	X	-	-	-
Drug Dispensing	-	X	X	X	-
Compliance	-	-	X	X	X
CBC	-	X	X	X	X
Iron Profile	-	X	X	X	X
HbA1C	-	X	-	-	X
Serum creatinine, bilirubin and SGPT	-	X	-	-	X

2.7. Drug compliance

At least two telephonic follow-ups will be made weekly to check whether the participant is taking the drug. SMS reminders will be sent to participants regarding their drug intake. Each participant will be asked to maintain a participant's diary, where all events and treatments will be documented. Drug compliance will be accounted for by maintaining telephonic call logs and cross-checking patients' diaries. Drugs will be dispensed at baseline and during the first and second follow-ups. Participants will be asked to bring their drug strips or containers and submit them to the study team. The study team will count the number of remaining pills and measure the weight of the remaining Drakshavaleha in the container to assess the compliance level.

2.8. Rescue measure

If the participant's Hb level at any time point during the study is found <8 g/dl, the patient will be referred to a hospital for further evaluation.

2.9. Adverse Drug Reaction (ADR)

Participants will be interviewed for any unexpected/untoward symptoms after administration of study drugs and any such events will be recorded for a description of the event, onset of event, management of the event, outcome of event, etc. Once an investigator becomes aware of an ADR, he/she will record the information in the ADR reporting form within 48 h. The principal investigator, or his designee, is responsible for notifying of all ADRs. After the initial report, the investigator will proactively follow each participant and provide further information for the medical monitoring of the participant's condition. ADRs will be followed until resolution; until no further changes in the event are expected; until the participant is lost to follow-up; or until it is agreed that further follow-up of the event is not warranted. The investigator/study team will comply with the applicable local requirements related to reporting of adverse reactions to the institutional ethics committee (IEC). ADRs leading to hospitalization, requiring immediate life-saving interventions, disabling, or causing death will be considered serious adverse drug reaction (SADR) which will be immediately (within 24 h) reported to the IEC. Detailed reports will be submitted to IEC within 14 calendar days.

IFA may cause gastrointestinal upset, abdominal pain, metallic taste, nausea, vomiting, constipation, diarrhea, black-coloured stool, and allergic reactions, whereas Drakshavaleha may cause gastrointestinal upset and loose stool at higher doses. In case the patient reports abdominal pain as an adverse reaction, the severity of pain will be assessed using the visual analog scale (VAS) score by project staff.

2.10. Outcome measures

Efficacy endpoints: Average improvement in Hb level at timepoint 1, 2, and 3 months; average serum iron, total iron binding capacity, serum ferritin, and transferrin saturation levels at baseline and 3 months; average RBC, MCV, MCH, and MCHC levels at timepoint 1, 2, and 3 months.

Safety endpoints: Proportions of treatment-emergent adverse reactions; proportions of participants with abnormal laboratory investigations (serum creatinine, serum bilirubin, SGPT and HbA1C).

2.11. Sample size calculation

The sample size is calculated based on the superiority trial design [parallel two-arm design]. With 5% alpha; 10% beta or 90% power; anticipated standard deviation (SD) in Hb level as 2; anticipated clinically significant difference (single drug vs. combination therapy) = 1 g/dl; in each group, 84 evaluable participants are needed. Considering a 20% attrition rate, the estimated sample size is 105 in each group and a total of 210. The sample size has been calculated using N master software.

2.12. Permitted medications

The medications like antihypertensive and other essential drugs, which the principal investigator feels non-interfering with the efficacy of study drugs, will be allowed to continue.

2.13. Withdrawal criteria

The withdrawal criteria for the study include the development of any adverse reaction that may affect the participant's continued participation, pregnancy during the study, and any clinical condition that the investigator believes may affect the study outcome or put the participant at risk.

2.14. Data management

All participant study-specific data will be captured in case record form (CRF). The investigator/assessor or authorized person will record all required participant data, and an explanation will be documented for any missing data. Source data will be kept in records and CRF will be verified against source documents. Any data discrepancy will be discussed and will be rectified with consensus with data clarification. The details of treatment, follow-ups, and expected visit date will be maintained with the participant in the form of the participant's diary. Deviations from the protocol or consumption of concomitant/rescue medications, if any, also will be entered in the CRF. The assessor/investigator will evaluate the diary on every visit during the follow-up. The confidentiality of the participant's information will be ensured by restricted access data handling.

2.15. Quality assurance

Data: The investigator will ensure the accuracy, completeness, legibility, and timeliness of the data recorded in the CRFs. The accuracy of the data entered on to the database for a subsample of individuals will be assessed, using double data entry. The data management team will cross-check the data for any missing values and discrepancies. Data in CRF will be verified with source data.

Conduct of the study: Scientists (who are not part of the study team) including mentors will monitor the study every 3 months. During monitoring, a team will verify the conductance of the study as per the approved protocol and applicable ethical and regulatory requirements. CRF and source data will be verified. Participant-specific files will be cross-checked and record keeping will be monitored. Feedback will be given to the study team for the need for improvement, if any. Laboratory investigations will be performed in NABL accredited laboratory with internal quality control and external quality assessment scheme in place.

2.16. Ethical considerations

The study will adhere to the ICMR National Ethical Guidelines for Biomedical and Health Research Involving Human Participants 2017. Institutional Human Ethics Committee (IHEC) has reviewed the study protocol and related documents. Study protocol has been approved from IHEC. Any amendments to the protocol or informed consent form (ICF) during the study will be submitted to the IHEC for approval. Prior to enrolment, participants will be provided with a Participant Information Sheet (PIS) in a language they understand. Written informed consent will be obtained from participants. Participants' confidentiality will be strictly maintained. An internal monitoring committee will be established to conduct periodic monitoring of the study processes. Data sharing and publication policy of ICMR will be followed.

2.17. Statistical analysis

All categorical variables will be summarised as frequency and percentage, Quantitative variables will be summarised as mean and SD if data follows normality else using median and interquartile range (IQR). A descriptive comparison of baseline characteristics between intervention and control groups to check that randomization produced broadly similar groups will be performed using Chi-square/Fisher's exact test/ANOVA/Kruskal Wallis test etc. Changes in biochemical parameters will be assessed as compared to baseline and average change in parameter will be compared between the study groups. One-way ANOVA/Kruskal Wallis test, Two-way repeated measures ANOVA/Generalized Estimating Equations (GEE) will be performed to check if is there any significant difference in the outcome variables before and after the interventions as well between the treatment groups. Multiple regression/GEE will be performed to adjust for the confounding variables. ANOVA/Kruskal Wallis test will be performed to study the association of change in hemoglobin level with various categories of Jatharagni in the study population. Imputation methods will be performed to handle missing data, if any. Modified intention-to-treat analysis for efficacy analysis, where all randomized participants with at least one follow-up visit data will be considered. Per protocol analysis will be done for safety analysis. P <0.05 will be considered statistically significant. Analysis will be performed using SPSS/EZR software.

3. Discussion

This protocol outlines a randomized controlled trial designed to evaluate the efficacy and safety of Drakshavaleha, an Ayurvedic formulation, in combination with IFA supplementation in women of reproductive age with mild to moderate IDA. The trial seeks to address the persistent challenge of anaemia in India, a condition that remains a significant public health concern despite extensive government efforts such as the Anemia Mukt Bharat programme. The rationale for this study is rooted in the need to enhance the efficacy of anaemia management strategies particularly in the context of the disappointing results with IFA supplements alone, where the prevalence of anaemia did not decrease as anticipated. While IFA supplementation is the standard treatment for IDA, issues such as poor compliance due to gastrointestinal side effects and suboptimal iron absorption have limited its effectiveness. Drakshavaleha, known for its potential to improve digestion, enhance iron absorption, and reduce gastrointestinal side effects, presents a promising option as a complementary therapy. The composition of Drakshavaleha and nutritional value are detailed in Table 2. In Ayurveda, it has been traditionally used alongside Punarnavadi Mandura for the treatment of anaemia, though limited scientific evidence exists to support this practice. While a few clinical trials registered in the CTRI are evaluating the efficacy of Punarnavadi Mandura and Drakshavaleha compared to iron and folic acid (IFA) supplements, no study to date has assessed the combined effect of IFA and Drakshavaleha. This study aims to provide crucial evidence on whether adding Drakshavaleha to standard IFA therapy results in superior outcomes, particularly in terms of hemoglobin levels and overall quality of life.

Table 2.

Ingredients in Drakshavaleha and nutritional value.

S.N.	Ingredients	Botanical Name	Part used	Quantity
1.	Draksha API	Vitis vinifera L.	Dry Fruit	768 gm
2.	Kana (Pippali API)	Piper longum L.	Fruit	768 gm
3.	Sarkara	Sugar	-	2.800 kg
4.	Madhuka (Yasti API)	Glycyrrhiza glabra L.	Root	96 gm
5.	Shunthi API	Zingiber officinale Roscoe.	Rhizome	96 gm
6.	Tvakshiri (Vamsa API)	Bambusa arundinacea (Retz.) Willd.	Silicacious Concretion	96 gm
7.	Dhatri (Amalaki API) Phala rasa	Emblica officinalis Gaertn.	Pericarp	12.288 L
8.	Madhu	Honey	-	768 gm
Nutritive value: •Fat 1.6g, carbohydrate 73g, protein 1g per 100g •Energy: 310 K Cal •Total Ascorbic acid 80 mg, Dehydroascorbic acid 62 mg per 100g •Iron 4 mg, calcium 3.3 mg, zinc 0.475 mg, copper 0.04 mg, Manganese 0.93 mg per 100g •Total dietary fibres 2.75g/100g •Fructose 15g, Glucose 27.5g, Sucrose 0.4g per 100g •Ash 0.8g/100g •Moisture 21g/100g

Should the intervention prove successful, it could represent a significant advancement in the management of IDA among women of reproductive age. Given the high prevalence of anaemia in India, the integration of Drakshavaleha into routine anaemia management could have broad implications, potentially reducing the burden of anaemia-related morbidity and enhancing the effectiveness of public health programs. Additionally, this study could contribute to the growing body of evidence supporting the integration of traditional medicine with conventional treatments, particularly in regions where access to healthcare is limited and the burden of nutritional deficiencies is high.

The study's design, a parallel group, randomized controlled trial, is robust and well-suited to provide high-quality evidence on the efficacy and safety of the intervention. The use of objective measures such as hemoglobin levels, red cell indices, and iron profiles ensures that the outcomes are quantifiable and comparable between groups. The inclusion of quality-of-life assessments adds a valuable dimension to the study, acknowledging that treatment success is not solely about clinical outcomes but also about the participants' overall well-being. The study also includes rigorous monitoring for adverse drug reactions, which is crucial given the potential side effects associated with both IFA and Drakshavaleha. By proactively identifying and managing any adverse events, the study ensures participant safety while also providing comprehensive data on the safety profile of the intervention.

Despite the strengths of the study, several challenges must be considered. Compliance is a significant issue in any long-term trial, especially when it involves daily medication. The study's design incorporates strategies such as telephonic follow-ups, SMS reminders, and participant diaries to enhance compliance, but these measures will require diligent implementation to be effective. Additionally, the open-label nature of the study may introduce bias, although the use of objective outcome measures mitigates this risk to some extent. Another potential challenge is the heterogeneity of the study population, particularly in terms of dietary habits, socioeconomic status, and baseline health status, which could influence both the efficacy of the intervention and the incidence of side effects. Stratified analysis or adjustments during statistical analysis might be necessary to account for these factors.

If this study demonstrates the efficacy and safety of Drakshavaleha in combination with IFA, it could pave the way for further research exploring the integration of traditional and modern medicine in the management of anaemia and other nutritional deficiencies. Future studies could also investigate the long-term effects of such interventions, as well as their applicability in different demographic groups, including children and the elderly. In conclusion, this study represents a promising step towards improving the management of IDA in India. By combining the strengths of traditional medicine with conventional treatment, it has the potential to offer a more effective and holistic approach to addressing one of the country's most pressing public health challenges.

4. Conclusion

The present study will generate evidence on the efficacy and safety of integrative therapy of Drakshavaleha with IFA supplements. It will help in finding the answer to whether this combination is superior to IFA supplements or not. It will also provide insight into the role of Drakshavaleha in enhancing the assimilation of oral iron from supplements and nutrition. If found superior, integrative therapy will be implemented in a program in collaboration with the State Government for reducing the prevalence of anaemia in selected districts through the Model Rural Health Research Unit.

Author contributions

M.B. conceptualized the study, drafted the initial manuscript, and revised it for finalization. K.M.K. provided statistical inputs, data management guidance, and assisted in drafting and revising the manuscript. C.M.S. and C.N. contributed to conceptualization, review, and manuscript finalization. H.H. provided protocol inputs, conducted the nutritional assessment of Drakshavaleha at ICMR-NIN, and finalized the manuscript. S.S.S. offered expertise on Ayurveda interventions and assisted with manuscript review and finalization. R.B.S. contributed to manuscript finalization. S.R. provided inputs during conceptualization, reviewed, and finalized the manuscript.

Declaration of generative AI use

Grammarly and Chatgpt were used only for language correction.

Funding sources

Trial has received funding from Indian Council of Medical Research Intramural Ignition grant.

Conflict of Interest

None

Data availability

No data was used for the research described in the article.