key: cord-1010592-decs51m7 authors: Hasheminasab, Fatemeh Sadat; Azimi, Maryam; Khodadoost, Mahmood; Choubani, Bahram; Shakeri, Nezhat; Ghasemi, Saeedeh; Farokhi, Azam; Mokaberinajad, Roshanak title: Efficacy of the barley-based remedy, a Persian medicine formula, in coronavirus disease 2019 (COVID-19) hospitalized patients: An open-labeled randomized controlled trial date: 2022-04-20 journal: Adv Integr Med DOI: 10.1016/j.aimed.2022.04.001 sha: 22cb0cb8cd7866c03c980668099913be1098bdb6 doc_id: 1010592 cord_uid: decs51m7 BACKGROUND: With the pandemic of coronavirus disease 2019 (COVID-19), and the growing attention of people around the world to the use of traditional and complementary medicines to control the disease, evaluating the effectiveness of these treatments has received special attention. AIM: This study aimed to assess the clinical efficacy of a barley-based remedy combined with conventional medicine in comparison to the conventional therapy in confirmed COVID-19 patients. MATERIALS AND METHODS: Seventy COVID-19 patients were randomly divided into barley-based remedy plus conventional medicine (barley-based remedy group) and conventional therapy (control group). Both groups were treated for 5 days. The outcomes were O(2) saturation, main symptoms (fever, respiratory rate, cough, and fatigue), and laboratory data (lymphocytic count, and CRP); they were measured for 6 days. RESULTS: In comparison to the control group, the O(2) saturation level in the barley-based remedy group significantly increased, from the second day of the intervention (P < 0.05). The herbal remedy significantly improved fatigue from the third day (P < 0.05). Meanwhile, the severity and frequency of cough between the groups were not significantly different. The herbal remedy had no significant effect on the CRP and the lymphocytic count of every time points of measurement. The average of respiratory rate and temperature of patients were in the normal range in both groups during the intervention. CONCLUSION: Barley-based remedy could significantly enhance the blood O(2) saturation and reduce fatigue. However, it needs to be confirmed by large sample size trials. In late December of 2019, the first case of coronavirus disease 2019 (COVID-19) was reported in Wuhan, China; currently, in late May of 2021, nearly 3.4 million and 160 million laboratoryconfirmed cases have been recorded in Iran and throughout the world, respectively. The disease has J o u r n a l P r e -p r o o f been become a major problem in human societies [1] . It should be noted, that the real number of cases is more than reports, and it is because of asymptomatic carriers, patients with mild symptoms or those who have atypical clinical manifestations [2] . COVID-19 is due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Older patients and those with comorbidity disorders such as diabetes or obesity potentially experience more severe disease [3] . Cytokine storm, pulmonary infiltration, alveolar damage and progressive respiratory failure may lead to worse conditions, and even death [4] . It is not practical to develop novel medication class within short span of time during current public emergency. In this regard different researches in modern and complementary medicine (i.e. Chinese herbal medicine, Persian medicine, acupuncture) are ongoing to find solutions to reduce the costs from the health care systems and reserve resources [5] [6] [7] . The experience during previous epidemics including severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) have demonstrated the effectiveness of traditional Chinese medicine for better management of the infection [8] . Moreover, the advantages of the integration of Chinese herbal medicine with conventional medicine are increase the cure rate and reduce the illness severity, hospital stay and mortality rate of COVID-19 cases, which have been indicated in previous studies [9] . The universal psychosocial impact caused by COVID-19 has led to raising panic and fear among the general population, with many individuals have preferred to try non-conventional therapies such as complementary medicine [10] [11] [12] . The recent cross-sectional study in Turkey proved the tendency of applying traditional and complementary medicine among general population, So, that almost 40% of the participants reported the usage of the traditional and complementary medicine. A significant proportion of believed that these modalities have fewer side-effects, are effective, and should be used for managing COVID-19 [12] . Another research in Iran indicated that 84% of general population applied at least one type of complementary and alternative medicine during the COVID-19 pandemic [13] . The overview of recent literatures of the efficacy of various forms of complementary and alternative interventions including Traditional Chinese medicine, acupuncture, Qigong, and relaxation showed that these modalities have a positive effect on ameliorating the different COVID-19 dimensions. They remarkably improved various physical symptoms (physical activity, inflammatory J o u r n a l P r e -p r o o f negative emotions, sleep quality) in patients with COVID-19 [14] . Persian medicine has been applied to ameliorate respiratory illness such as pneumonia for thousands of years. Several papers have been introduced the Persian medicine herbs, their relevant pharmacological properties, and also their possible mechanisms to alleviate COVID-19 signs and symptoms [15] [16] [17] . It should emphasis, that conducting clinical trials to evaluate the efficacy of these remedies against current epidemic is a necessity. These trials will pave the way to design further researches to identify and extract the bioactive phytochemical components, and potentially lead to the discovery of new drugs against SARS-CoV-2. The mixture of Hordeum vulgaris L., Ziziphus jujube Mill., and Cordia myxa L. have been recommended in Persian medicine manuscripts as a type of barley-based remedy (Ma-al-Shaeer in Persian) for treating pneumonia. H. vulgaris is the main component of this formula [18, 19] . Not only, it has been widely used as a popular food, but also as a safe remedy since ancient time. Its antiinflammatory property is remarkable [20] . Z. Jujuba traditionally is considered as a good remedy for controlling infection, fever and cough. Recent studies confirmed the anti-viral, immunomodulatory, anti-inflammatory, and neuroprotective effects of this medicinal plant [21] [22] [23] [24] . The other herb is C. Myxa, which alleviates sore throat, cough and respiratory infections. According to the scientific researches, it has various therapeutic potentials such as anti-viral, anti-inflammatory, analgesic, and antitussive actions [25] [26] [27] . In this project, we aimed to evaluate the efficacy of the barley-based remedy treatment in adult COVID-19 hospitalized patients. for ICU admission, taking corticosteroid, recent usage of herbal medicine, diabetes, hypertension, asthma, allergy, chronic renal failure, chronic heart failure, chemotherapy, and immune deficiency. At first, the written informed consents were obtained from the eligible patients, then they were randomly divided into intervention (barely-based remedy) or control groups. All of them received conventional therapy based on the Protocol for Diagnosis and Treatment of Novel Coronavirus Pneumonia (5th edition). The barley-based remedy was added to the conventional medication regimen of the patients in the intervention group. The dosage of herbal water extract was 200 ml, two times a day, for five days. All eligible participants were randomly allocated to the intervention (barley-based remedy) and control groups. A randomization list was generated by a biostatistician, in Blocked Randomization Method (non-stratified, four patients in each block) using Random Allocation Software. The primary outcome was O2 saturation percentage (SpO2). The secondary outcomes were as follows: body temperature, cough severity (range from 0 for no cough to 4 for severe cough with chest J o u r n a l P r e -p r o o f discomfort), and cough frequency (0 for no cough to 10 for cough all day (Fisman Cough Score [28] ), fatigue (visual analogue scale (VAS)) [4] , Respiratory rate, C-Reactive Protein (CRP), lymphocyte count, mortality rate, and adverse effects. The primary and the secondary outcomes were measured daily during whole six days of intervention. Due to lack of previous study, the sample size was considered 35 subjects in each group [29] . Demographic information was compared between the two groups via the Chi-square and student t-Test. The student t-test was also used for comparing the changes between the two groups in different time point. The statistical analysis was performed using SPSS 24 and the resultant p<0.05 was considered significant. Afterwards total ash, loss on drying and extractive value percent were determined according to herbal pharmacopeia method to evaluate the quality of purchased herbs. In order to quantify the active compounds of herbs, total phenolic content and flavonoid content of Z. jujuba and C. myxa were determined. Total phenolic content of mentioned plants was determined spectrophotometrically using the Folin-Ciocalteu reagent assay according to a previously described method with slightly modification [30] . Briefly, 100 μL aqueous extract of the herbs or a standard solution of gallic acid was added to a test tube, then mixed with 500 μL of diluted Folin-Ciocalteu reagent (1:10 v/v) and the resulted mixture was slightly shaken for a minute. Afterwards, 400 μL of an aqueous solution of Na2CO3 (7.5% w/v) was added and the obtained mixture was incubated for 30 min in the darkness at room temperature. After incubation, the absorbance, relative to that of a blank prepared using distilled water, was measured at 765 nm using multi-mode microplate reader (BioTek®, USA). The concentration of total phenolic compounds was determined as mg of gallic acid/ g of the dry weight of extract by using regression equation that obtained from the calibration curve of the gallic acid. Colorimetric method was used to measure the amounts of total flavonoids in the plant [31] . For this purpose, different concentration of rutin and quercetin standard (500-62 μg/mL) was prepared in methanol 60%. One ml of aqueous extract of Z. jujuba or C. myxa or methanolic solution of rutin and quercetin standard was mixed with 1 mL distilled water. Then 100 μL sodium nitrate 5% was added to each sample and shacked for 6 min. afterwards 200 μL aluminum chloride 10% was added to each test tube. After 5 min incubation at room temperature 1 mL aqueous solution of NaOH (1 N) was added and the absorbance, relative to that of a blank prepared using methanol 60%, was determined at 510 nm using multi-mode microplate reader (BioTek®, USA). All tests were carried out in triplicate and the results were expressed as mean±SD. At last, the medicinal plants were delivered to the Mofatteh hospital, Varamin city. On a daily basis, 60 grams of crushed herbs mixture (in equal proportion) was gently boiled with 1200 ml of water, until 400 ml liquid was remained. Then, it was filtered. The patients took the 400 ml water extract in two divided doses (200 ml morning, and 200 ml evening). The hospital nutritionist made this decoction. The phytochemical analysis of herbs of barley-based formulation is presented in Table 1 . The total ash is under 11 % and loss on drying is below 6% for all evaluated herbs. In the study of total phenolic content, C. myxa significantly showed more phenolic content (119.85±4.84). Also, the amount of flavonoid compounds including rutin and quercetin in C. myxa fruits was significantly higher than Z. jujuba. Flowchart of the study Seventy eligible subjects were equally entered into two groups. In the barley-based remedy group, two cases were excluded due to lost to follow up, and one was excluded because of discontinued intervention; the remaining 32 subjects completed the trial. In the control group, two patients were omitted from the project due to lost to follow up and 33 subjects completed the study. Figure 1 shows the flow chart of the study. In term of gender, 14 (43.8%) of patients in barley-based remedy group, and 17 (51.5%) of cases in control group were male. The mean age of participants in barley-based remedy and the control groups were 51.49 ± 11.61 and 53.28 ± 13.22 year, respectively. There was no significant difference in terms of age and gender between the groups (p>0.05). The baseline clinical manifestations of the participants are shown in Table 2 . No significant difference was detected regarding the initial clinical characteristics including temperature, respiratory rate, cough, O 2 saturation, fatigue, CRP and lymphocyte count (p>0.05). The participants were re-assessed at the first six days after starting the intervention. The average of the respiratory rate and body temperature was in the normal ranges during intervention days. The barley- According to the results of this study, the herbal remedy significantly improved the level of O2 saturation one day after starting the intervention, and remained meaningful until the end of the study. The fatigue was significantly reduced on the 3rd day and remained significant until the 6th day. The difference in the severity and frequency of cough, body temperature, respiratory rate, CPR, and lymphocyte percentage were not significant between the two groups. The significant outcome of this trial is the improving effect of barley-based remedy on O2 saturation of COVID-19 patients compared to the control group; although during the intervention period, the average of O2 saturation could not reach higher than 94.3% in the barley-based remedy. It should be noted, that the mean O2 level of the control group was not higher than 89.25% during the intervention period. The improvement in oxygen levels may be due to the potent anti-inflammatory effects of the components of the barley-based formula. Barley, like some other organism species contain a group of polysaccharides named β-glucans, which are responsible for a variety of biological activities such as regulation of the immune responses [32] . Recent researches demonstrated, that barley β-glucans decreases systemic inflammation. It reduces the leukocyte superoxide and TNFα production. It also lessens stimulator of interferon genes expression [20] . Another study showed, that polysaccharide conjugates of the Z. Jujuba could decrease IL-10 levels of the chronic fatigue syndrome rats [21] . Moreover, saponin isolated from the fruits of this herb significantly reduces the inflammation via several pathways such as COX-2 inhibition [22] . Another study indicated that Betulinic acid, an active substance of Z. Jujuba have satisfactory antiviral activity against influenza A/PR/8 virus. In addition, betulinic acid is able to alleviate the symptoms of edema and lung necrosis due to influenza A/PR/8 virus in mice [23] . The phytochemical screening conducted on C. myxa fruit extract showed the presence of flavonoids, glycosides, saponins, alkaloids, terpenoids, phenolic acids, tannins, and mucilage [33] . Regarding to different pharmacological investigations, C. myxa revealed anti-inflammatory, analgesic, immunomodulatory, antimicrobial, respiratory, and cardiovascular protective properties [27] . Recent According to these studies, polyphenols of Z. Jujuba, and also jujuboside A, which is a saponins isolated from this herb could prevent isoproterenol-induced cardiomyocytes injury [37, 38] . The temperature averages of patients in both groups were blow 37.2 C every day during the six days of follow up, except for patients in barley-based remedy group at the onset of admission with temperature of 37.4 C. So, all patients were afebrile, and it is justified due to receiving naproxen by all patients. During the intervention days, the average of respiratory rate in both groups was in normal range, and no significant different was detected. The normal rate of respiration at the same time as the O 2 saturation level decreases, may be justified by the silent hypoxia mechanism reported in COVID-19. Silent or happy hypoxia has been generally defined as hypoxia in the absence of dyspnea and tachypnea [39] . Recent studies have theorized some possible mechanisms of this event in COVID-19 patients, such as possible direct interaction between the virus and hemoglobin, and neural cell damage due to viral infection and consequently imbalance of neurotransmitters or endogenous neuropeptides [40, 41] . It could be concluded, that barley-based remedy, as an adjunct treatment is enable to significantly enhance the blood O 2 saturation. Even though the final level of O 2 was less than normal, this improvement as a result of a safe remedy consumption is considerable. 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Material preparation, collection of data and analysis were per-formed by Hasheminasab