The trial protocol was reviewed and approved by the institutional ethics committee, Mahatma Gandhi Ayurveda College Hospital and Research Centre, Salod (Hirapur), Wardha, Maharashtra, India, IEC Ref No. MGACH/IEC/April-2021/202 dated 09.04.2021. The enrollment of patients was initiated only after receiving the CTRI registration number, CTRI/2021/08/036034 received dated 31/08/2021. Every procedure involving human participants complies with the 1964 Helsinki Declaration and its subsequent amendments, as well as the institutional and/or national research committee’s ethical requirements. We ensured that each patient gave their written informed consent before recruiting them. Participants received comprehensive information about the study’s goals, interventions, possible risks, and advantages. They are made aware of their freedom to leave at any moment without repercussions. Throughout the study, each patient’s privacy will be protected. The confidentiality of participants is rigorously respected. Unique participant numbers are used to anonymize all personal information, and the data are safely stored on password-protected systems with limited access. No publication arising from this research will reveal any personally identifiable information. No financial payment was made to participants for taking part. Because the interventions utilized in this study comprise well-established medications with recognized safety profiles (standard metformin and Ayurvedic formulations), no risk is involved.

This study was an interventional study (randomized open-labeled standard controlled equivalence clinical trial). This whole protocol is designed as per the guidelines of the SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials) Checklist(Checklist 1).

The sample size is limited due to practical constraints such as funding unavailability, study duration, and participant considerations. For this pilot Phase II study, 18 participants per group (total n=36) are proposed, accounting for a 10% dropout. While a formal power calculation is not required, this size offers approximately 90% power to detect an increase in the primary outcome from 32% to 70% at a 5% significance level. This range is appropriate for estimating parameters to inform a future definitive randomized controlled trial while maintaining feasibility and resource efficiency [13-18].

Eligible participants with T2DM will be identified from inpatient and outpatient departments of the institute. Those meeting the inclusion criteria will be approached for written informed consent. Individual patients will be added until the desired sample size is attained.

After obtaining consent and performing baseline assessment, participants will be randomly allocated into intervention or control groups via simple randomization using a computer-generated table method.

Participants may withdraw from the study at any time. Those who withdraw before starting the intervention will be replaced to maintain the intended sample size. However, participants who withdraw after receiving part of the intervention (eg, after 30 days) will be considered dropouts and included in the intention-to-treat analysis. They will not be replaced, as their data remain valuable for assessing safety and efficacy. Participants who develop acute or life-threatening conditions or show non-compliance will also be excluded from the study.

The patients diagnosed with ICD-10-CM Diagnosis Code E11.9, that is, newly diagnosed patients with T2DM having a duration of disease of <6 months and having fasting blood sugar levels between 126 and 200 mg/dl and post-meal blood sugar level between 140 and 300 mg/dl will be recruited in the study via simple randomization using the computerized generated table method.

As it is a pilot study, ecruitment rate (number recruited/month), ligibility rate (number eligible/number screened), retention rate at 45 days, compliance with intervention (percentage of prescribed doses taken), adherence to follow-up investigations, acceptability of intervention (based on participant-reported feedback), and data completeness rates are variables. Moreover, the reduction in Blood sugar levels (fasting and postprandial), HbA_1c, and urine sugar level values of patients with T2DM will be also assessed to calculate the effect size.

The duration of intervention for both groups is 45 days. The first and second follow-ups will be on the 45th day and 90th day of study, respectively.

The computer-generated table will be used for convenient randomization in the recruitment of patients. The main investigator and co-investigator will assign and enroll the patients. The researcher generates random allocation cards using computer-generated random numbers. The researchers will store the initial randomly selected sequences in a secure place, and the patients will use a separate copy. Serial numbers will be written on the outside of the envelopes for the purpose of blinding. The envelope will contain the following necessary information: the date, time, patient ID, postintervention results, and others.

Reminders for appointments and question-and-answer sessions will be created to keep patients engaged in the project. The patient file will include information about the whole follow-up, and if patients are asked to stop or withdraw, the file will be closed and kept on file for documentation purposes.

After the completion of the study, observations will be noted and drawn from case record forms with thorough examinations, history, and assessment sheets; findings of values of biochemical parameters; and a proforma for follow-up evaluation.

The lead investigator and a co-investigator will handle data monitoring and coding. A hard-copy case record form and soft-copy data entry will be completed. The values will be checked twice before being sent in electronic format. A unique patient code protects every patient file and planning for collecting, assessing, and managing auditing adverse events.

The trial conduct will be audited quarterly by an independent monitoring team using a predefined checklist to ensure adherence to the study protocol and regulatory compliance.

The initial analysis of participant responses commenced in January 2025. The outcomes from this phase are anticipated by June 2025. Objective measures, including reductions in fasting and postprandial blood glucose levels and HbA_1c values, will be monitored and documented. After CTRI Registration, a delay occurred in the recruitment of patients due to a delay in the availability of raw drugs and the preparation of the Ayurveda medicine as a result of some administrative issues.

Statistical comparisons between the Ayurvedic formulation and metformin groups will be performed using the Mann-Whitney U test for continuous variables and χ²/Fisher exact test for categorical variables.

Only descriptive statistics, confidence intervals, and exploratory calculation of variability—avoidance of P values where appropriate—will be reported; no hypothesis testing will be done. All analyses will be conducted using a recent version of the SPSS software (version 25.0, IBM Corp), and results will be interpreted as exploratory due to the small sample size.

T2DM is a chronic metabolic disorder with a rising global prevalence. Ayurvedic formulations have shown promise in managing hyperglycemia through multiple mechanisms, such as antioxidant and insulin-sensitizing effects. As common people always prefer herbal drugs due to their safe and non-invasive nature, the Ayurvedic herbal formulation, that is, Nimba-Amalakyadi formulation, selected for this trial consists of seven herbs including Nimba (Azadaricta nimba Linn.), Amalaki (Embelica officinalis Linn.), Haridra (Curcumin longa Linn.), Kutaj (Holarerna antidystentrica Linn.), Vijaysara (Pterocarpus marsupium Linn.), Pippali (Piper longum Linn.), and Marich (Piper nigram Linn). The Prameghna (hypoglycemic action) of each herb can be explained based on the classical textual references from Ayurveda and modern science as described below.

Nimba is an important ingredient of Nimba-Amrutadi Erand, an effective Ayurvedic medicine for DM. The hypoglycemic effect, that is, a significant reduction in blood sugar levels in adrenaline and glucose-induced hyperglycemia due to aqueous extracts of Neem leaves, has been discussed [19]. He also quotes that aqueous extracts of Neem leaves are also effective in controlling streptozotocin-induced diabetes. The hypoglycemic effect of the aqueous extracts of Neem leaves may be due to the rich content of the flavonoid quercetin that potentiates insulin secretion from the pancreas. The Nimba-Amalakyadi formulation is quite effective due to its anti-hyperglycemic potential to lower peripheral glucose utilization and block the effects of epinephrine on glucose metabolism in diabetic and normal rats [20].

Amalaki is the main ingredient of one of the Ayurvedic formulations, Dhatri-Nisha Yoga, whose efficacy has been proven by several clinical studies [14-18]. It is quite a common drug in clinical practice for the management of DM. The large content of vitamin C, tannoids, and polyphenols present in Phyllanthus Emblica L is useful to control diabetes by controlling oxidative stress and avoiding hyperglycemia along with hyperlipidemia induced by it. It reduces the blood sugar level in diabetes by enhancing insulin secretion by stimulating the pancreas [21].

Haridra is considered the best hypoglycemic herb in Ayurveda. The rhizome of Haridra possesses hypoglycemic action due to its Tikta, Katu Rasa (bitter and pungent taste as per Ayurveda), Ushna Virya (hot potency), Katu Vipaka (pungent effect after digestion as per Ayurveda), Laghu (easy for digestion), and Ruksha (dry nature) properties. Haridra breaks the pathogenesis of the disease by balancing the disturbed Vata, Pitta, and of Kapha, all of which are vitiated in T2DM as per Ayurveda. The anti-diabetic effect of Haridra may be due to the curcumin present in its rhizomes that reduce insulin resistance and oxidative stress. It also protects insulin-secreting cells in the pancreas. The three main constituents, that is, curcumin, dimethoxy-curcumin, bisdemethoxycurcumin, and ar-turmerone, reduce hyperglycemia via peroxisome proliferator-activated receptor-gamma activation [22].

The anti-diabetic potential of Kutaja (especially its seeds and bark) is explained by Saroya [23]. Kutaja pacifies Kapha Dosha, the main culprit pathogenesis of Prameha due to its Tikta, Kashaya Rasa (bitter and astringent taste as per Ayurveda), Katu Vipaka (pungent effect after digestion as per Ayurveda), Laghu, and Ruksha properties. The antioxidant and antidiabetic properties of Kutaja are based on the rich content of flavonoids and phenolic compounds present in its bark. Such anti-diabetic effects may be induced by enhancing the uptake of liver glycogen and glucose [24].

Flavonoids in Kutaja possess an antioxidant property that reduces hyperglycemia induced by oxidative stress. Vijaysara is one of the hypoglycemic herbs used to prepare Bijak Glass (Nisha Herbal company) or Nisha-Kathakadi Choorna (powder)and Qwath (decoction). The hypoglycemic activity of the wood of Vijaysara in dogs was shown by Singh et al [25]. This effect was due to the pterostilbene and tannates present in it [24].

Pippali and Marich possess Katu-Tikta Rasa, and Laghu, Snigdha, and Tikshna properties that have Kaphaghna (a phlegmn-alleviating effect) and Dipana (digestion enhancers) actions. Both herbs also induce immunomodulation due to their Rasayana (rejuvenative) properties useful in Prameha. Their Kapha–Medoghna (alleviation of phlegmn and fat) property and Prameghna action (anti-diabetic activity) were proved by Reddy [26] and Khaliq et al [27], respectively.

In a nutshell, most of the ingredients of Nimba –Amalakyadi Yoga (formulation) are primarily Katu and Tikta Rasa Dravyas, Kledahara (absorbing hydrous content in the body) and Agnidipaka (enhancement in digestive fire) in nature. The Kledaghna properties of Tikta Rasa, useful in the management of Prameha, are described by Acharya Charaka based on its Panchbhautik (made of Panchamahahabhuta) composition, that is, the predominance of Vata and Akasha Mahabhuta that induces Stroto Vishodhana (channel-clearing effect) effect due to its Sukshma Guna (easy penetration capacity at the micro-cellular level). All the above-mentioned herbs are natural immunomodulators due to their Rasayana (rejuvenating) property that reduces oxidative stress and hyperglycemia induced by it. Moreover, it also prevents further Dhatu Kshaya (tissue emaciation) present in Prameha due to the vitiation of Vata and causes improvement in the clinical features of Prameha due to this Rasayana property.

The anti-diabetic effect of all these herbs may be induced by increasing insulin secretion or enhancing insulin sensitivity at the receptor level, promoting the regeneration of ß cells, reducing the absorption of glucose from the gastrointestinal tract, lowering blood glucose level through the improved peripheral utilization of glucose, decreasing their resistance, decreasing oxidative stress by the inhibition of superoxide radicals or hydroxyl radical scavenging activity or converting reactive oxygen species to non-reactive products, lowering cholesterol levels by the inhibition of lipid peroxidation.

Based on the above clinical shreds of evidence, the study was planned with this formulation to assess the synergistic hypoglycemic effects of herbs. In patients with diabetes, this can become a scientific approach for the clinical management of DM, which becomes a ray of hope for such patients. At the same time, the efficacy of Nimba Amalakyadi Choorna will be more than that of metformin for the management of T2DM.

Preliminary observations from this pilot study suggest favorable trends in glycemic control with the Ayurvedic formulation, aligning with previous studies demonstrating the hypoglycemic effects of herbs such as Pterocarpus marsupium and Curcuma longa [28, 29]. Unlike studies that lacked comparator arms [30, 31, 32], our protocol directly compares the Ayurvedic formulation with metformin, providing a more rigorous assessment.

The feasibility outcomes will be revealed in terms of the steady recruitment through outpatient services, participant compliance in percentage, and the tolerability of both interventions along with the observation of any major adverse effects. Some logistical challenges, such as coordinating follow-up visits, will be mitigated through flexible scheduling.

This pilot study will inform a future full-scale RCT by providing estimates of the effect size, participant retention rates, and potential refinements to intervention protocols. However, the limitations include a small sample size, short trial duration (45 days), and the lack of statistical power for definitive efficacy conclusions. The limited sample size due to limited financial assistance is the study’s major limitation. Moreover, patients with other types of diabetes, for example, those with type 1 DM, or juvenile or gestational DM, were excluded from this study. Further clinical trials in these populations with similar interventions can be planned in the future.

Upon completion, data will guide protocol adjustments for a larger, adequately powered RCT aimed at validating the clinical efficacy and safety of the Ayurvedic formulation in managing T2DM. If the intervention offers significant results, then safe, cost-effective, time-saving, and alternative treatment in Ayurveda can be identified for patients with T2DM who are not willing to undergo Panchakarma Therapy or are contraindicated for conventional existing treatment modalities.

If this trial yields effective and promising results, it could provide clinical evidence supporting the efficacy of a safe, herbal alternative to metformin for managing T2DM. This Ayurvedic formulation may offer an option for individuals who seek Ayurveda treatment but cannot undergo procedures like Vamana (therapeutic emesis) or Virechana (therapeutic purgation), or those who struggle with strict dietary and lifestyle modifications required for Panchakarma therapies. It may also appeal to those wary of mineral-based hypoglycemic drugs. The trial would highlight the synergistic hypoglycemic effects of Nimba-Amalakyadi Yoga, a combination of herbs with proven hypoglycemic properties. Future studies could expand on this research with larger sample sizes and compare its effects to Shodhana therapies like Vamana and Virechana in patients with T2DM. Further clinical trials could explore its potential in treating juvenile diabetes, pregnancy-induced diabetes, or drug-induced DM.