Nerium plant. One among cardia poisons and upavisha according to Ayurvedic categorization.

1. KARAVEERA
Dr Anu Mariam Varghese
II nd MD Scholar
Dept of Agadatantra
GAVC,TVM

2. CONTENTS
O Cases
O Prevalence
O In Ayurveda
O Introduction, synonymous, Types, Class of poison
O Botanical description
O Toxic principles, Toxicodynamics and Toxicokinetics
O Toxic part, Fatal dose, Fatal period
O Diagnosis,Treatment ,PM appearance
O Medicolegal importance
O Sodana, Parts used, medicinal dose
O Therapeutic uses, folkfore uses, Antidote
O Agada yogas and other yogas
O Research works
O References

3. Case 1
O A 14 years old boy presented with vomiting, loose stools and
giddiness.
O Had a history of consumption of 1 oleander..
O Examination revealed bradycardia with irregular rhythm
O Electrocardiograph (ECG) showed sinus bradycardia with pauses.
O Stomach wash was given with activated charcoal. Temporary
pacemaker implantation was done. Pacemaker was removed at the
end of 48hours as ECG showed normal pulse rhythm.
O DIAGNOSIS : Yellow oleander poisoning

4. CASE 2
O . A 42-year-old woman with a known history of malignant mesenchymal
cancer was admitted to the emergency department with vomiting,
gastrointestinal distress and cardiac symptoms with digoxin-
like toxicity of 4 hour duration. Her complaints began within an hour of
ingesting a bowl of Nerium oleander blooms which she took to reduce
the pain caused by the cancer
O . Oleandrin was detected in the blood sample at a concentration of 14.7
ng/ml.
O With the conservatie management the patient became stable
O DIAGNOSIS : Oleander poisoning

5. PREVALENCE
O In India, the overall percentage of plant poisoning ranges from 6% to
15%, and for rural population alone it can be high as 63% and the
oleander contributes most.
O Most imp cause of livestock poisoning reported in South Africa.
O At present yellow oleander poisoning has a 10% mortality rate in Sree
Lanka
O Ranks equally with mushrooms as major cause of children’s admission
to hospital after accidental plant ingestion worldwide.

6. IN AYURVEDA -KARAVEERA
O Mentioned in Brhatrayis, Laghutrayi s and Nighantus.
O One among upavisha in later texts like RT, RRS, YR etc..

7. Common Oleander Yellow Oleander
O Nerium odorum
Nerium indicum
O Apocynaceace
Common names
O White oleander, Pink
oleander, Rose laurel, Rose
bay, Rosa francesca, Laurier
rose, Adelfa
O Cerbera thevetia,
Thevetia peruviana,
T.nereifolia
O Apocynaceae
O Bastard oleander, Exile
oleander, Be-still tree, Lucky
nut, Tiger apple

8. O Regional name
O Sankrit name
O Hindi
O Tamil
: Arali
: Karaveera
: Kaner, Kanail
: Alari
O Synonymous
• Hyamaraka or Asvamaraka
• Karaveera
• Chandata
• Sataprasaha
• Pratihasa
• Angulipatraka

9. - Systemic ; Cardiovascular
Class of poison
O Modern
O Ayurvedic
Charaka, Susrutha ,AS – Moola visha among sthavara
BP, RT, RRS, YR - Upavisha
O Types
– 3 varietes ;
•Kaiyadeva Nighantu, Bhavaprakasha Nighatu
Sveta, Rakta, Peetha
•Raja Nighantu – 4 varities ; Sveta, Rakta, Peetha, Krishna

10. Karaveera mentioned as Upavisha a/c
different texts
R.R.S R.T Y.R B.P R.S.S R.C R.K.D RVM R.Ci A.P
Karaveera + + + + + + + + + -
R.S.S
R.C
– Rasendra Sara Sangraha
– Rasendra Chudamani
R.K.D –Rasa Kamadenu
RVM – Rasarnavam
R.Ci – Rasendra chintamani
A.P – Ayurveda Prakasha

11. Classical categorization
Charaka Kushtaghna, Tikta skandha, Moola visha
varga, Tikta varga
Susrutha Lakshadi gana, Siro virechana gana, Moola
visha varga, Tikta varga
Vagbhata Lakshadi gana
Bhavaprakasha Nighantu Guloochyadi varga, Vishoparisha varga
Raja Nighantu Karaveeradi varga
Shodala Nighantu Karaveeradi varga, Paniya varga
Saligrama Nighantu Guloochaydi varga
Madhanapala Nighantu Hantakyadi varga
Dhanwanthari Nighantu Upavishagam of Misrakadi sapthamovarga

12. BOTANICAL DESCRIPTION
Common Oleander
O Habitat
Many subtropical and tropical areas
of the world.
Large evergreen ornamental shrub,
2-6 meters height
O Leaves
Long, narrow, lanceolate, leathery,
dark-green on upper surface, lighter
beneath, 10-25 cm
Yellow Oleander
O evergreen tropical shrub or
small tree, Ornamental (grows
to about 30 feet height)
O Pointed, lanceolate , dark
green upper surface, lighter
green undershades, edges-
rolled

15. Common Oleander Yellow Oleander
O Flowers
Pink,or white fragnant flowers
( with terminal clusters
O Fruit
Long narrow capsule, 8 to 10 cm
long, split open at maturity to
release numerous downy seeds
O Seeds
Pod is slim, cylindrical, ribbed ,
turns brown, dries and splits,
releasing small seeds tipped with
coma of light brown hairs, light
and dusky
O large ,yellowish funnel
shaped flowers
O Globular, light green,
contains single nut which is
triangular with a deep
groove along edge.
O Each nut contains 5 pale
yellow seeds. Seeds are
vaguely heart shaped.

19. RASA PANCHAKA
Rasa
Guna
Veerya
Vipaka
: Katu, Tikta, Kashaya
: Laghu, Rooksha, Teekshna
: Ushna
: Katu
Doshakarma
Prabhava
Karma
: kaphavatasamana
: Hridya
: Hrdhya, Raktasodhana, Svasagna, Kushtagna,
Kandugna, Swedajanana, Jwaragna,
Bandaka, Vrnasodhana, Ropana, Sothahara,
Deepana, Vidahi, Pachana, Bhedana

20. TOXIC PRINCIPLES
Yellow Oleander
Common Oleander
O Cardiac glycosides-
• Oleandrin (oleandroside)
• Nerin (nerioside)
• Folinerin
• Rosagenin
• Digitoxigenin
• Neriodorin, Neriodorein
• Karabin
• Oxalate crystals (leaves)
• Peruvoside
• Ruvoside
• Thevetin A
• Nerifolin
• Cerberin
• Thevetin B

21. TOXICOKINETICS
Cardiac glycosides- Toxic to cardiac myocytes and autonomic system
O Inhibit Sodium- Pottasium ATPase
O Increasing Cardiac Contractibility
O Decreasing AV conduction and heart rate.
A cardiac glycoside has 2 parts 1- carbohydrate , 2- aglyconic portion
• Carbohydrate- imp for solubility ,absorption and bioavailability.
• Aglyconic portion – divided into steroid backbone and unsaturated
lactone ring- role in primary interaction with receptor

24. Inhibit Na+-K+ -ATPase pump
an extracellular portion of the pump
Binding occurs within
Decreases
the active transport of Na+ with consequent excretion of
pottasium Increased intracellular sodium levels
leads to inhibition of NCX( Na+/ Ca 2+ exchanger)
Increased level of Ca 2+ in intracellular space
positive inotropic effect of cardenolides and toxicity
Na, Ca cause partial membrane depolarisation which increases
automaticity and ventricular ectopy

25. IN CARDINOMYOCYTES
O Leads to increased contractibility ( + ve inotropic effect)
O Reduce velocity of electrical conduction ( -ve dromotropic
effect) via AV node depression.
O Reduction of heart rate( -ve chronotropic effect) via SA node
depression.
O In neurons of vagal nerve leads to reduced velocity of
electrical conduction which causes reduced heart rate via a
reflexive reduction of sympathetic transmission

26. OLEANDRIN
O Due to prominent lipophilicity.
O Results in slow urinary excretion.
O Longer duration of action as cardio toxic agent.
O Rapid and conspicuous GI absorption with bioavailability
30 % .

27. TOXICODYNAMICS
INGESTION
• Frothy salivation
• Difficulty in swallowing & articulation
• Tingling and burning sensation in mouth and tongue.
•Dryness of throat
GIT
•Vomiting,
•Pain in the abdomen
• Nausea
•Diarrhea
CVS
• Pulse first slow , later rapid and weak
• Hypotension
• AV block

28. • Marked bradycardia –Acute overdose
• Ventricular tachycardia –severe toxicity
• Ventricular Fibrillation
CNS
Locally
Skin contact dermatitis
• Delirium • Lethargy
• Dizziness • Drowsiness
• Occasionally seizures and
coma
• Rarely xanthopsia
• Headache

29. O Tetanic spasm
O Lock jaw
O Hyperkalemia – severe poisoning common
O Metabolic acidosis
O Asphyxial symptoms -later
O Respiratory paralysis , Death
Inhalation
• Headache • Respiratory difficulty
• Dizziness • Nausea

30. In Ayurveda,
O Moola visha lakshana –Susrutha
• Udweshnam - Voluntary stretching of the body
• Pralapam - Delerium
• Moham – Delusion

31. Common Oleander Yellow Oleander
O T
oxicpart
All parts esp root, including
nectar
seeds = roots > fruits > leaves
O Fatal dose
15-20 g root
5-15 leaves
O Fatal period
20-36 hours
All parts esp seeds and root
seeds = roots > fruits > leaves
O 8-10 seeds
15-20g root
5-10 leaves
O 2-3 hours

32. DIAGNOSIS
O Radio-immunoassay
O Fluroscence polarization immunoassay
O Thin layer chromatography
O Fluroscence spectrophotometry
O Reverse –phase HPLC and HPLC/MS –more specific
O Liquid chromatography(LC) with high resolution
masspectrometer (HRMS)
O LC-MS/MS - best of forensic interest

33. ECG
Potentially severe cardiac arrhythmias
• Premature ventricular beats.
• T-wave inversion or flattening.
• Deformed ST segment( “scooped” or “sagging” ST segments)
• ↓ QT interval
• ↑PR interval
• Atrial tachycardia with AV block.

34. TREATMENT
O Gastric lavage, activated charcoal
O Measure urea, electrolytes, magnesium and creatinine. Serum
potassium correlates cardiac toxicity.
O Hyperkalemia life threatening – IV bicarbonate, glucose, insulin.
O ECG monitoring
O Cardiac arrhythmias with anti rhythmic drugs
O Correction of fluid and electrolytic imbalances

35. O Atropine , Adrenaline, Noradrenaline for sinus bradycardia
and A-V block
O Digoxin-specific antibody fragments (Anti-digoxin fab
fragments)
O Correct hypotension by adequate fluid resuscitation with a
crystalloid.
O Correction of metabolic acidosis
O Hemodialysis or hemo perfusion
O Symptomatic treatment.

36. According to Ayurveda
Buffalo curd mixed with sugar
Buffalo milk with powder of arka twak.

37. O Same treatment mentioned in KriyaKoumudhi

38. POSTMORTEM APPERANCE
Common Oleander
O Not characteristic
O Congestion of organs.
O Fragments of root may be
present in the stomach
O Petechial hemorrhages seen
on surface of heart
O Can be detected long after
death.
O Resist heat ,therefore can
be detected even from burnt
dead body
Yellow Oleander
O Not specific
O Stomach and deodenum
may be congested
O May show fragments of
seeds
O Subendocardial
ecchymoses
O Resists putrefaction and
can be detected long after
death in exhumed putrefied
bodies

39. MEDICOLEGAL IMPORTANCE
O Accidental poisoning - from its use in traditional medicine
• Herbal tea
• Children and animals may be attracted by its flowers
• Smoke from burning plant.
• When plant material used as firewood poisonous sap
transferred into food may be lethal
• Root is taken internally for treating venereal diseases.
• Root , used for treating cancers and ulcers as paste.
• Decoction of leaves externally to reduce swelling
O Suicidal – decoction or paste prepared from leaves, fruit or
root is common in rural areas.

40. O Homicidal rare – Powdered kernel of fruit mixed with alcohol.
O Abortifacient , root either locally or taken internally
O Cattle poison – juice of root is applied on piece of cloth and
inserted into anus of animal.
Also seeds are crushed and fed to animal with corn or bread.

41. SODHANA
O Dolayantra swedana of Karaveera with cow’s milk for 3
hrs Then wash with hot water and
get dried
( Yogaratnakara )
 Cardenolide content less in post sodhana sample
 Preparative TLC and LC-MS showed reduction in
oleandrin peak

42. Principles Pre Shoditha Post Shoditha
Saponins Absent Present
Alkaloids Present Absent
Carbohydrates Present Present
Proteins Present Present
Steroids Present Present
Triterpinoids Present Present
And in the post sodhitha sample absolute absence of
symptoms found in toxicity studies that when
compared with pre sodhitha sample.

43. PART USED
O Moolam, Moolatwak, Patrm
MEDICINAL DOSAGE
Choorna : 30-125 mg
(API)

44. THERAPEUTIC USES
• Cardio tonic • Antipyretic
• Anti helminthic • Antiseptic
• Cardiac asthma • Circulatory disorders
• Fever • Leprosy
• Respiratory disorders • Skin diseases
• Anti-inflammatory • Antimicrobial
• Locomotor activity • Anti-Leukemic
• Anticancer • Immuno-modulating
• Diuretic

45. O In Indralupta after Gada prachana ,lepana with juice of
Karaveera and honey is mentioned (AH.U.24.29)
O In Sannipata Udara along with madya moolakalka of
Kakadani, gunja and Karaveera mentioned (visha prayoga) –
(AH.Chi. 15.78)
O In Arsas, for lepana leaves of Karaveera along with other
drugs like sigru, nimba etc.. macreated with snuhi ksheera
mixed with hingu mentioned – (AH.Chi.8.23).
O In Kikkisa, Karaveera patra sidha Taila abhyanga for mardana
mentioned –(AH.Sa.1.61)

46. O Kaphaja Visarpa – Lepana of karaveera with other drugs like
triphala, ushira ….- (Ca.Chi 18.14)
O Visha Chikitsa – If any visual impairement, Anjana by devadru,
trikatu,karaveera etc by triturating with ajamootra.(Ca.Chi
.23.69)
O Apachi – karaveera taila is used as nasya (Su.Chi.18/22)

47. FOLKLORE USES
O Administration of choorna of root bark of Nerium oleander
cures Bronchitis, Bronchietasis, Emphysema.
O The seed oil is applied externally to treat skin infections.
O Toxic bites- External application of Nerium oleander.
O Dermatitis – Macerated leaved of oleander may be applied.
O Macerated leaves of oleander also used in superficial tumor,
syphilis, loss of hair.
O Gingivitis –Decotion of oleander leaves have been used.

48. ANTIDOTE
O Antidote for Karaveera is Haritaki

49. AGADA YOGAS
O Sarvakarmika Agada – friuts and flowers of
Karaveera –AH.Utt.36.70
O Yapana Agada – AS.Utt 40.68.

50. OTHER YOGAS
O Malathyadi Tailam
O Kanakaksheeri taila
O Vajraka Tailam
O Brhat kaseesadi Tailam
O Karaveera Tailam
O Karaveeradya Tailam
– AH.U.24/24
– Ca.Chi 7/114
– Su.Chi 9/54, AH.Chi 19/79
– BP.5/60-62
- Chakradhatta 50/49
– Rasa Tarangini 24.493

51. RESEARCH WORKS
O Studies available regarding yellow oleander as a weight loss
supplement, antibacterial, antifungal, anti inflammatory effects
etc...
O Anti cancer agent – Leaf extract of Nerium oleander L. inhibits cell
proliferation, migration and arrest of cell cycle at G2 /M phase in
HeLa Cervical Cancer Cell.
O Oleandrin : A bioative phytochemical and potential cancer killer via
multiple cellular signaling pathways.
O Phytoremediation for urban landscaping and air pollution control- a
case study in Trivandrum city, Kerala, India. (pubmed)

52. O Analytical study of effect of sodhana on peetha karaveera moola
(Thevetia nerifolia juss ex Steud)- Praseethamol.K, K.V.G Ayurveda
medical college, Sullia.
O A comparative analytical study of moola of sweta karaveera (Nerium
indicum Mill) and peeta karaveera (Thevetia nerifolia juss)w.r.s to its
purification –Dr Pavithra. P, K.V.G Ayurveda medical college, Sullia.
O Safety and efficacy of karaveeradi taila as Lomashaatana on healthy
volunteers – Dr Anjana Mohan , K.V.G Ayurveda medical college,
Sullia.
O Pharmacological and phytochemical evaluation of karaveera beeja
(Thevetia nerifolia Juss ex Steud) w.s.r to its purificaion-
Dr.U.Santhosh Nayak, Alva’s Ayurvedic medical college & hospital.

53. REFERENCES
O https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6723884/
(assessed on 11 may 2021 10.32 am)
O https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6996654/ (assessed
on 11 may 2021 11.52 am)
O Comprehensive Medical Toxicology,3rd Edition ;V V Pillay,page no 963
O The essentials of forensic medicine &Toxicology; 34th edition Dr K.S N
Reddy ; Dr O P Murthy, page no 573
O International Journal of Applied Ayurved Research ISSN: 2347-6362 ;
A review of Karaveeraand its therapeutic utlitity

54. O Rasa Tarangini of Sri Sadananda Sarma; Dr Ravindra
Angadi, 1st edition, page no 484-485.
O Pharmacological and phytochemical evaluation of karaveera
beeja (Thevetia nerifolia Juss ex Steud) w.s.r to its
purificaion- Dr.U.Santhosh Nayak.
O Kriyakoumudhi-V.M .Kuttikrishna Menon page no 751
O A textbook of Agadatantra – Dr .U.R.Sekhar Namburi, page
no 110-114.
O A textbook of Agadatantra- Dr Sobha Bhat.K, page no 138-
142

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