key: cord-0912387-6vuy2h0b
authors: Khorshiddoust, Reza Ramazani; Khorshiddoust, Saleh Ramazani; Hosseinabadi, Tahereh; Mottaghitalab, Faezeh; Mokhtari, Farzad; Azadinia, Fatemeh; Mozdarani, Hossein; Shabani, Mohammad; Emadi-Kouchak, Hamid; Taheri, Bahram; Khani-Juyabad, Fatemeh; Kashani, Mina Amjadi; Sadoughi, Arezoo; Zamanizadeh, Sorour; Maddah, Hadyeh; Aminzadeh, Maedeh; Khanaki, Maryam; Saremi, Sabereh; Rad, Anahita Pashaee; Fatehi, Ali; Rad, Melika Ghaznavi; Haftbaradaran, Masoud; Khosroshahi, Mehran; Sadeghi, Mahtab; Aminnayeri, Majid; Jafari, Sirous; Ghiasvand, Fereshteh; Seifi, Arash; Ghaderkhani, Sara; Manshadi, Seyed Ali Dehghan; Salehi, Mohammadreza; Abbasian, Ladan; Hasannezhad, Malihe; Meidani, Mohsen; Hajiabdolbaghi, Mahboubeh; Ahmadinejad, Zahra; Parash, Masoud; Sedighi, Zahra; Mohammadian, Abdorreza
title: Efficacy of a multiple-indication antiviral herbal drug (Saliravira®) for COVID-19 outpatients: A pre-clinical and randomized clinical trial study
date: 2022-02-17
journal: Biomed Pharmacother
DOI: 10.1016/j.biopha.2022.112729
sha: a2a2c5405b348938700c3bdc239a226de113e152
doc_id: 912387
cord_uid: 6vuy2h0b

BACKGROUND: The scientific researches on COVID-19 pandemic topics are headed to an explosion of scientific literature. Despite these global efforts, the efficient treatment of patients is an in-progress challenge. Based on a meta-study of published shreds of evidence about compounds and their botanic sources in the last six decades, a novel multiple-indication herbal compound (Saliravira®) has been developed. Based on the antiviral, anti-inflammatory, and immune-enhancing properties of its ingredients, we hypothesized that Saliravira® has the potential to act as an antiviral agent, accelerate treatment, and reduce undesirable effects of COVID-19. METHODS: In this randomized, controlled, open-label clinical trial, COVID-19 outpatients were included by RT-PCR test or diagnosis of physicians according to the symptoms. Participants were randomly divided into intervention and control groups to receive Saliravira® package plus routine treatments of COVID-19 or routine treatments of COVID-19 alone, respectively. Saliravira® package includes tablets, nasal-sinuses spray, oral-pharynx spray, and inhaler drops. The treatment was for 10 days and followed up till 23 days after admission. RESULTS: On the 8(th) day, the “mean reduction rates” of viral load of the patients in the intervention group was 50% lower compared to the control group with a p-value < 0.05. The improvement of 10 out of 14 COVID-19 symptoms in the intervention group was significantly accelerated. The mean treatment duration of patients in the intervention group was 4.9 days less than the control group. In addition, no patients in the intervention group were hospitalized compared to 28% of the control group needed to be hospitalized. DATA AVAILABILITY: Data supporting reported results that is not given here is available on request from the corresponding author. This data is not publicly available due to privacy requirements.

2 Abstract 1 Background 2

The scientific researches on COVID-19 pandemic topics are headed to an explosion of scientific 3 literature. Despite these global efforts, the efficient treatment of patients is an in-progress challenge. 4 Based on a meta-study of published shreds of evidence about compounds and their botanic sources in 5 the last six decades, a novel multiple-indication herbal compound (Saliravira ® ) has been developed. 6 Based on the antiviral, anti-inflammatory, and immune-enhancing properties of its ingredients, we 7 hypothesized that Saliravira ® has the potential to act as an antiviral agent, accelerate treatment, and 8 reduce undesirable effects of COVID-19. 9

In this randomized, controlled, open-label clinical trial, COVID-19 outpatients were included by RT-11 PCR test or diagnosis of physicians according to the symptoms. Participants were randomly divided 12 into intervention and control groups to receive Saliravira ® package plus routine treatments of COVID- 13 19 or routine treatments of COVID-19 alone, respectively. Saliravira ® package includes tablets, nasal-14 sinuses spray, oral-pharynx spray, and inhaler drops. The treatment was for 10 days and followed up 15 till 23 days after admission. 16

On the 8 th day, the "mean reduction rates" of viral load of the patients in the intervention group was 18 50% lower compared to the control group with a p-value < 0.05. The improvement of 10 out of 14 19 COVID-19 symptoms in the intervention group was significantly accelerated. The mean treatment 20 duration of patients in the intervention group was 4.9 days less than the control group. In addition, no 21 patients in the intervention group were hospitalized compared to 28% of the control group needed to be 22 hospitalized. 23

The morbidity and mortality of COVID-19 increases daily. The confirmed and probable cases exceed 28 340 million patients and 5.5 million deaths [1] . Acute COVID-19 is a multi-organ disease with a broad 29 range of manifestations, Patients suffer from prolonged and persistent post-COVID impacts that can be 30 harmful and devastating [2] [3] [4] [5] . It is expected that more than half of the world will have been infected 31 with the omicron variant by the end of March 2022 [6] . It seems that COVID-19 as a pandemic will 32

To evaluate the effects of the pharmaceutical composition of the SaliraVira ® composition, 20 C57BL/6 97 inbred mice were studied for acute and chronic prescription . The mice were housed in an animal house  98   for one week, provided with proper light, temperature and moisture and fed with standard mouse food  99 pellets and water ad libitum. Seven-week-old mice weighing 23 ± 5 g were used for the experiments. 100

The mice were randomly divided into four groups, twenty mice were included in control groups and 101 twenty mice were included in the treatment group for evaluating acute and chronic toxicity. 

The participants were assigned to two groups by the block randomization method. In order to minimize 156 the probability of sequence prediction, blocks with variable sizes (4 and 6) were used. The 157 randomization ratio was 1:1 and was performed by Random Allocation Software [28] . The physicochemical analyses of Saliravira ® indicated the total flavonoids determined, based on 211

Hyperoside, was 0.048 mg/ml. Also, based on BP 2017 and using a standard oven, the dry residue of 212 100 gr of the extract was 2.81 w/w. Using a pycnometer, the density of the solution was 0.82 kg/liter. 213

The total alcohol content in the Saliravira ® package was under permitted daily exposure (PDE) based 214 on "APPENDIX 6. TOXICOLOGICAL DATA FOR CLASS 3 SOLVENTS" of the US FDA 215

Guidance. Finally, based on USP-40, the microbial contamination tests of the extract indicate, the 216 numbers of all bacteria were zero and the amount of yeast in the extract was less than 10. 217 218

The study of hematological factors in the test of control groups in both acute and chronic treatment did 220 not show a significant difference, which is indicated in Figure 1 

Based on the modified WHO CRF for COVID-19 outpatients, 14 symptoms of the patients in both 291

intervention and control groups were tested daily during treatment. By the 8 th day of treatment, there 292 was a remarkable improvement in the overall situation of the intervention patients. The comparative 293 results are shown in Table 2 . The "efficacy" of treatment is measured by the "probability" of changes 294

in symptoms in both groups, and the "significance" of the efficacy is shown by the relevant "p-values". 295

The p-value in each group is one-sided and compares the probability distribution of the COVID-19 296 symptoms on the n th (i.e., 4 th , 6 th , 7 th , and 8 th ) day to the 1 st day of treatment. 297 J o u r n a l P r e -p r o o f 15 As indicated, on the 4 th day of treatment, with a probability of at least 95%, the improvement of 3 of 14 298

symptoms of COVID-19 (i.e., joint-pain, muscle-aches, and wheeze) in the intervention group were 299 significantly and efficaciously preferred to the control group. Also, on the 6 th day of treatment, with a 300 probability of at least 90%, the improvement of 7 of 14 symptoms (i.e., sore throat, headache, 301

shortness-of-breath, decreased-smell, abdominal-pain, inability-to-walk, and rhinorrhea) in the 302 intervention group were significantly preferred to the control group. 303 4 out of the 7 symptoms (i.e., headache, abdominal-pain, inability-to-walk and rhinorrhea) in the 304 intervention group were efficaciously preferred to the control group. With a probability of at least 95% 305 on the 6 th day of treatment, the improvement of 5 out of 14 symptoms (i.e., sore-throat, headache, 306

shortness-of-breath, abdominal-pain, and inability-to-walk) in the intervention group were significantly 307 preferred to the control group. Also, 4 out the 5 symptoms (i.e., sore-throat, headache, abdominal-pain, 308

and inability-to-walk) in the intervention group were efficaciously preferred to the control group. 309

On the 7 th and 8 th treatment days, with a probability of at least 90%, the improvement of 4 out of 14 310 symptoms (i.e., decreased-taste, fatigue, altered-consciousness-confusion, and chest-pain) in the 311 intervention group were significantly preferred to the control group. Also, 2 out of 4 symptoms (i.e., 312 fatigue and altered-consciousness-confusion) in the intervention group were efficaciously preferred to 313 the control group. In the treatment time span, with a probability of at least 95%, the improvement of 2 314 out of 14 symptoms (i.e., fatigue and altered-consciousness-confusion) in the intervention group were 315 significantly and efficaciously preferred to the control group. 316

Results from the evaluation of the COVID-19 symptoms in intervention and control groups in the 8 th 317 day treatments with a probability of 90% indicate that Saliravira ® is more significant for all 14 318 symptoms and more significant and efficaciously for 10 of 14 symptoms. The results of 8 th -day 319 treatments show that Saliravira ® , with a probability of 95%, is more significant for 10 symptoms and 320 more significant and efficaciously for 8 of 10 symptoms. 321 322 323 Figure 6 indicates that the "CDF of treatment duration" of patients in the intervention group with a 327 mean of 8.8 and standard deviation of 5.5 days. With a probability of 87%, the patients treated by the 328 Saliravira ® package were recovered on the 10 th day of taking Saliravira ® . The difference of the 329 treatment duration of intervention and control with a p-value < 0.05 is tested by both one-sided 330 hypothesis test and mutually inclusiveness of their domains. 331

The "CDF of treatment duration" of patients in the control group with a mean of 13.7 and standard 332 deviation of 3.3 days was shown in 

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J o u r n a l P r e -p r o o f 18 A broad review of the literature was performed, focusing on the viral proteins of SARS-COV, the 359 inhibitory compounds, and the physical interactions between the compounds and the viral proteins 360 predicted by molecular docking methods [29] [30] [31] [32] [33] [34] . This resulted in detecting 54 inhibitory compounds in 361 Saliravira ® and 13 inhibited viral proteins in SARS-COV. 362In fact, SARS-COV2 has 29 different proteins, including 16 nonstructural proteins, some proteases and 363polymerases [35] . 13 viral proteins, i.e., NSP1, NSP3, NSP4, NSP5, NSP10, NSP12, NSP13, NSP14, 364 NSP15, M pro, E pro, S pro, N pro are inhibited by Saliravira®. Among these 13 viral proteins, S pro, 365 M pro, and NSP5 are the most affected proteins by inhibitory compounds of Saliravira® That is, these 366 top 3 viral proteins are inhibited by 30, 23 and 21 inhibitory compounds of Saliravira®, respectively. 367As previously mentioned, Saliravira ® has "immune enhancing", "anti-viral" and "anti-inflammatory" 368properties. These features are related to the return the normal functionality of "Type 1 interferon 369 pathway", "suppression of viral replication or infection processes", and "NF-kB signaling pathway" in 370