Traditional Chinese Medicine in the Treatment of Patients Infected with 2019-New Coronavirus (SARS-CoV-2): A Review and Perspective.

Currently, Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2, formerly known as 2019-nCoV, the causative pathogen of Coronavirus Disease 2019 (COVID-19)) has rapidly spread across China and around the world, causing an outbreak of acute infectious pneumonia. No specific anti-virus drugs or vaccines are available for the treatment of this sudden and lethal disease. The supportive care and non-specific treatment to ameliorate the symptoms of the patient are the only options currently. At the top of these conventional therapies, greater than 85% of SARS-CoV-2 infected patients in China are receiving Traditional Chinese Medicine (TCM) treatment. In this article, relevant published literatures are thoroughly reviewed and current applications of TCM in the treatment of COVID-19 patients are analyzed. Due to the homology in epidemiology, genomics, and pathogenesis of the SARS-CoV-2 and SARS-CoV, and the widely use of TCM in the treatment of SARS-CoV, the clinical evidence showing the beneficial effect of TCM in the treatment of patients with SARS coronaviral infections are discussed. Current experiment studies that provide an insight into the mechanism underlying the therapeutic effect of TCM, and those studies identified novel naturally occurring compounds with anti-coronaviral activity are also introduced.


Introduction
In December 2019, there was an outbreak of unexplainable pneumonia in Wuhan city, Hubei province, China [1]. By Jan 7, 2020, it was confirmed that a new type of coronavirus named SARS-CoV-2 (formerly named as 2019-nCoV) had emerged [2]. The World Health Organization (WHO) named the Wuhan pneumonia as Coronavirus Disease-2019 (COVID-19) on Feb 11, 2020 [3]. The COVID-19 patients showed typical respiratory symptom (such as cough, fever, and lung damage) and some other symptoms such as fatigue, myalgia, and diarrhea [4,5]. As of February 17, 2020, a total of 73,332 cases of the SARS-CoV-2 infected pneumonia has been reported in China and 25 other countries, of which 72,528 cases was found in China [6]. Due to the rapid spread of SARS-CoV-2 through human-to-human transmission, the cases currently continue to rise. SARS-CoV-2 extracted from patients with pneumonia in Wuhan is an enveloped single stranded RNA-type beta-coronavirus [7]. The genome sequences of SARS-CoV-2 shared 79.5% sequence identity to severe acute respiratory syndrome-related coronaviruses (SARS-CoV) [8,9]. In addition, the spike (S) protein of SARS-CoV-2 and SARS-CoV enters human alveolar epithelial cells through binding angiotensinconverting enzyme 2 (ACE2) receptor [8].
COVID-19 can be diagnosed by either chest CT radiography or a laboratory testing. Unfortunately, specific antiviral drugs or vaccines currently have not been available for the treatment [10,11]. According to Ivyspring International Publisher the current clinical guideline in China and the experiences in the treatment of SARS or Middle East Respiratory Syndrome (MERS) patients, both conventional medicine and traditional Chinese medicine (TCM) are used for the treatment of patients with infection of SARS-CoV-2 in China [12][13][14]. This review mainly focuses on the discussion of TCM usage in the treatment of COVID-19 patients, in the context of current conventional management. Due to the homology in epidemiology, genomics, and pathogenesis of the SARS-CoV-2 and SARS-CoV [8,9], and widely usage of TCM in the treatment of patients infected with SARS-CoV in 2002-2003, the clinical evidence showing the efficacy and safety of TCM in the treatment of patients with the emerging coronaviral will be summarized and analyzed, including the laboratory studies that provide an insight into molecular basis of therapeutic benefits.

Conventional treatment of SARS-CoV-2: is there a room for Chinese medicine?
Due to the absence of a specific antiviral therapeutics and vaccine, main treatment strategy for COVID-19 is supportive care, which is supplemented by the combination of broad-spectrum antibiotics, antivirals, corticosteroids and convalescent plasma [16] (Table 1). HIV protease inhibitors ritonavir and lopinavir have been used, typically in combination with appropriate antibiotics or with IFNα-2b, in the treatment of SARS-CoV-2 infected patients [7,17]. Nucleoside analogs such as ribavirin [12] may be potentially beneficial for the treatment of COVID-19, since ribavirin was approved for treating respiratory syncytial virus (RSV) infection [18] and used extensively during the SARS and MERS outbreak [10]. However, ribavirin had severe side effects such as anemia [18] and whether it had sufficient antiviral activity against SARS-CoV-2 is unclear. Nucleoside analogs favipiravir (T-705) can effectively inhibit the activity of RNA polymerase of RNA viruses such as influenza [19]. A recent in vitro study found that it had the anti-SARS-CoV-2 activity [20], but the in vivo effect remains elusive. Remdesivir may be the most promising antiviral drug for treating COVID-19. It has in vitro and in vivo antiviral activity against a wide array of RNA viruses including SARS and MERS [21], and could decrease viral loads and pathology of lungs in animal models [22]. A study showed remdesivir markedly inhibited the infection of SARS-CoV-2 in Vero E6 cells [20], and most symptoms of the first US patient infected with SARS-CoV-2 had resolved swiftly after intravenous administration with remdesivir [23]. Currently, it is under clinical trial to evaluate the safety and efficacy of intravenous remdesivir for patients with SARS-CoV-2 infection [24]. Oral oseltamivir has been used for the treatment of the cases with SARS-CoV-2 [7], while its efficacy currently remains uncertain. Host-targeted small molecules approved for other human diseases may modulate the virus-host interactions of SARS-CoV-2. Chloroquine, a potential broad-spectrum antiviral drug [25,26], was shown by a recent study had anti-SARS-CoV-2 activity [20]. Its clinical efficacy is under study in an open-label trial (ChiCTR2000029609) [12]. IFNα (5 million U) atomization inhalation was recommended as antiviral therapy to treat SARS-CoV-2 [16]. A trial testing IFNα-2b combination of the approved anti-HCV inhibitors has been initiated [17], however, whether it could act synergistically against SARS-CoV-2 is unclear.
Corticosteroids were frequently used to suppress the elevated cytokine levels in patients with 28] and 30]. However, there are no evidence showing that the mortality of SARS and MERS patients was reduced by the treatment with corticosteroids, while the clearance of viral was delayed by such treatment [31][32][33]. Consequently, corticosteroids are not suggested to systemically use in SARS-CoV-2 infected patients [34,35].
Previously, it was shown that, either in severe influenza or SARS-CoV infection, convalescent plasma treatment could significantly decrease viral load and reduce the mortality [31,36]. Convalescent plasma has been used for severe SARS-CoV-2 infection in China [22], although promising, the efficacy and safety need to be carefully further evaluated.
Consistent with previous analysis, WHO also concluded "to date, there is no specific medicine recommended to prevent or treat SARS-CoV-2" [37]. TCM has been used in control of infectious diseases for thousands of years. There is a clear room for the intervention of TCM as a complementary therapy for COVID-19 patients. It is reported that the patients with SARS-CoV infection have benefited from TCM treatment [38], including amelioration of side effect of conventional therapeutics [39,40]. Based on these factors, there is a general expectation that TCM would be a valuable weapon in the armory against SARS-CoV-2.

Traditional Chinese Medicine in the treatment of patients infected with SARS-CoV: clinical evidence
Application of TCM in the treatment of SARS-CoV-2 is largely inspired by the treatment of SARS caused by outbreak of SARS coronavirus (SARS-CoV) in the late of 2002 in the Guangdong Province of China which spread rapidly during the 2003, with the cumulative number worldwide of over 8,000 [41][42][43]. Ranging from case reports, case series, controlled observational studies and randomized clinical trials, clinical studies aiming to examine the effect of TCM on SARS have been carried out and reported. There are quite compelling evidences support the notion that TCM has beneficial effect in the treatment or prevention of SARS. For example, the rate of fatality in Hong Kong and Singapore was approximately 18%, while the rate for Beijing was initially more than 52% until the 5 th of May and decreased gradually to 4%-1% after the 20 th of May in 2003. The dramatic reduced fatality from late May in Beijing was believed to be associated with the use of TCM as a supplement to the conventional therapy [44]. Lau [45,46]. In a controlled clinical study, the supplementary treatment with TCM resulted in marked improvement of symptoms and shortened the disease course [47]. The clinical beneficial effect of TCM appears to be supported by laboratory studies. For example, a high-profile research published in the Lancet reported that glycyrrhizin, a major active constituent liquorice root which is the most frequently used Chinese herb, potently inhibited the replication of clinical isolates of SARS virus [48]. Another independent study confirmed the antivirus activity of glycyrrhizin by plaque reduction assays and this study found that another Chinese herbal compound baicalin also had the anti-SARS activity [49]. Furthermore, Wang et al. found MOL376, a compound derived from TCM, may become a lead compound for SARS therapy by inhibition of cathepsin L, a target for the treatment of SARS [50].
There is a myriad of literature on TCM treatments for SARS published after the SARS epidemic in China. A critical analysis of these publications would be useful to confirm the beneficial effect of TCM. Liu et al. systematically reviewed eight randomized controlled trials, and concluded that, by combination with conventional medicine, TCM showed the beneficial effects such as decrease of mortality and relief of symptom, as well as control of fungal infections in patients with SARS. However, the evidence is not sufficient enough due to the poor quality of methodology used in the trials [13]. Leung analyzed 90 peer-reviewed papers with reasonable quality from 130 publications and concluded that TCM used together with conventional treatment had some positive effects, including better control of fever, quicker clearance of chest infection and other symptoms. However, such beneficial effect of TCM is not conclusive and more high-quality clinical studies are required [15]. In another thorough literature analysis, Liu and colleagues concluded that there was no benefit of adjuvant treatment with TCM in terms of mortality [39]. Due to the lack of high quality TCM trials and biases that influenced the validity of results, Wu and colleagues suggested to re-run clinical trials of TCM for the treatment of acute respiratory tract infections (ARTIs) [51].

Identification of anti-novel coronaviral compound from Traditional Chinese Medicine
Natural products used in TCM remains to be a wealthy source for the identification of novel therapeutic agents for the treatment of human diseases [52]. In the past decade, scientists have made a considerable effort to identify multiple component herbal formulae in TCM with anti-SARS-CoV activity ( Table 2). Further identification of chemical entities contained in TCM herbs responsible for the anti-SARS-CoV effect was also pursued (Table 3). Due to the homology of SARS-CoV and SARS-CoV-2, these previous studies may shed light on the naturally occurring compounds with the capacity to inhibit SARS-CoV-2.
3-chymotrypsin-like protease (3CLpro) is vital for replication of virus, and thus represents a promising drug target for the development of therapeutics agents for SARS-CoV as well as other human coronaviruses including SARS-CoV-2. It was reported that following TCM herbal extracts had the capacity to inhibit the enzymatic activity of SARS 3CLpro: Chinese Rhubarb extracts (IC50: 13.76 ± 0.03 μg/mL) [53], water extract of Houttuynia cordata [54,55] [48,75], quercetin and TSL-1 extracted from Toona sinensis Roem [76] purportedly had potent anti-SARS-CoV effects by inhibition of viral cellular entry, adsorption, and penetration.
Overwhelming inflammatory responses are attributable to the deaths of patients with infection of SARS-CoV, or MERS-CoV, or COVID-19. Thus, anti-inflammatory agents presumably could reduce the severity and mortality rate [77]. Shuang Huang Lian, a TCM herbal product prepared from Lonicerae japonicae Flos, Scutellariae radix and Fructus Forsythiae, purportedly had the activity to inhibit SARS-CoV-2 [78]. Interestingly, We have shown that this herbal preparation potently inhibited staphylococcal toxic shock syndrome toxin 1 (TSST-1)-induced production of cytokines (IL-1β, IL-6, TNF-α, IFN-γ) and chemokines (MIP-1α, MIP-1β and MCP-1) by peripheral blood mononuclear cell (PBMC) [79]. In line with our results, this herbal product was shown to markedly reduced the transcriptional and translational levels of inflammatory cytokines TNF-α, IL-1β, and IL-6 in lipopolysaccharide-stimulated murine alveolar macrophages [80]. Indirubin is an active ingredient of a TCM preparation Dang Gui Long Hui Pill, had strong antiviral and immunomodulatory effects, as shown by a study based on the observation of influenza H5N1 virus-infected human macrophages and type-I alveolar epithelial cells [81]. Lian Hua Qing Wen Capsule was reported to have in vitro activity in inhibition of propagation of various influenza viruses. This TCM herbal product not only blocked the early stages of influenza virus infection but also inhibited virus-induced gene expression of IL-6, IL-8, TNF-a, IP-10, and MCP-1 [82]. Additionally, a study by Dong et al. reported that the levels of IL-8, TNF-α, IL-17, and IL-23 in the sputum and of IL-8 and IL-17 in the blood were markedly decreased after Lian Hua Qing Wen Capsule treatment in patients with acute exacerbation of chronic obstructive pulmonary disease [83]. A self-control study by Poon et al. showed that the administration of the TCM herbal formulas (Sang Ju Yin and Yu Ping Feng San) may have beneficial immunomodulatory effects for the prevention of viral infections including SARS-CoV [46].
Moreover, a number of anti-coronaviral agents have been identified from TCM herbs, although the mechanisms of action have not yet been elucidated.   (Table 5).

Traditional Chinese Medicine used in the treatment of SARS-CoV-2-infected patients: the current situations
Through analysis of the frequency of TCM used in 23 provinces, Luo,et al. [37] concluded that Astragalus membranaceus, Glycyrrhizae uralensis, Saposhnikoviae divaricata, Rhizoma Atractylodis Macrocephalae, Lonicerae Japonicae Flos, Fructus forsythia, Atractylodis Rhizoma, Radix platycodonis, Agastache rugosa, and Cyrtomium fortune J. Sm were 10 most commonly used Chinese herbs in the treatment of COVID-19. Xu,et al. [91] reported that Astragalus membranaceus and Yu Ping Feng were used in the 13 prevention programs (in Beijing, Tianjin, et al.) for "reinforcing vital qi", a terminology used in TCM that is similar to boosting host defense capacity. Ophiopogon japonicas and Scrophularia ningpoensisand are TCM herbs which were most frequently used for "nourishing yin" in northern China, while Atractylodis Rhizoma, Agastache rugosa and other Chinese medicinal herbs with the property of "aromatic dehumidification" were commonly used in southern China (Table 6).   Re Du Ning Injection, Tan Re Qing Injection, Xing Nao Jing Injection, Qing Fei Pai Du Tang Critical cases Xue Bi Jing Injection, Re Du Ning Injection, Tan Re Qing Injection, Shen Fu Injection, Sheng Mai Injection, Shen Mai Injection, Su He Xiang Pill, An Gong Niu Huang Pill  According to the report of National Administration of Traditional Chinese Medicine, up to February 5th, 2020, 214 COVID-19 patients were treated with Qing Fei Pai Du Tang in Shanxi, Hebei, Heilongjiang and Shaanxi Provinces with overall effective rate ≥ 90%. Among them, the symptoms of majority of patients (≥60%) were markedly improved, while illness of others (30%) was stabilized [92]. After that, 701 COVID-19 patients were treated with Qing Fei Pai Du Tang in 10 provinces in China. The result showed that 130 patients (18.5%) were completely cured after treatment. The treatment also resulted in the disappearance of characteristic symptoms of COVID-19 such as fever and cough in 51 patients (7.27%). In addition, symptom improvement or stabilization were observed in 268 patients (38.2%), and in 212 patients (30.2%), respectively [87]. Yao,et al. and Lu,et al. [93,94] retrospectively analyzed the clinical efficacy of Lian Hua Qing Wen Capsule in treatment of confirmed and suspected COVID-19 patients. The results indicated that this herbal product could markedly relieve major symptoms such as fever and cough and had the capacity to promote the recovery.
Some patients with mild illness in the early stage could suddenly progress to severe disease, and eventually died due to septic shock with multiple organ dysfunction syndrome (MODS), which was associated with cytokine storm [95]. There is compelling evidence that some TCM herbal products or its components have potent immunosuppressive effects, as shown by our own and other's studies [79,[96][97][98][99][100][101][102][103]. For example, Wang,et al. [104] reported that Shen Fu Injection could inhibit the lung inflammation and decrease the levels of IL-1β, IL-6 and other cytokines. Chang,et al. [105] reported that Re Du Ning Injection could markedly reduce the levels of IL-1β, TNF-α, IL-8, IL-10, and some other cytokines of LPS-induced model of acute lung injury in rats. We recently reported that tetrandrine, a compound isolated from an anti-rheumatic Chinese herb, could potently inhibit proinflammatory Th1, Th2 and Th17 responses in LPS-challenged mice [106]. Therefore, TCM with the capacity to inhibit cytokine storm and its devastating consequences may be harnessed in the treatment of severe COVID-19 patients.
Currently, the laboratory study on the effect of TCM is apparently lagging behind the clinical application of TCM in the treatment of COVID-19 patients. Nevertheless, some scientists have started to examine the effect of TCM products or its components on SARS-CoV-2 in their laboratories. For example, an in vitro study showed that Shuang Huang Lian Oral Liquid had the inhibitory effect on SARS-CoV-2 [78]. However, its clinical efficacy and safety for the treatment of COVID-19 patients has not been evaluated. We noticed that this TCM product was not recommended by HNC's Guideline [89]. Same as SARS-CoV, SARS-CoV-2 uses receptor ACE2 for the cellular entrance [8]. Theoretically, blockade of ACE2 can prevent the infection of SARS-CoV-2. Chen and Du thus performed the molecular docking study and they found that TCM-derived compounds, including as baicalin, scutellarin, hesperetin, glycyrrhizin and nicotianamine could interact with ACE2 [107]. Therefore, these compounds as well as herbs containing these ingredients may have the capacity to inhibit the infection of SARS-CoV-2. We anticipate more experiment studies showing anti-SARS-CoV-2 activity of TCM or its components will be published in the near future.

Closing remarks
TCM has accumulated thousand-of-year's experiences in the treatment of pandemic and endemic diseases. Providing complementary and alternative treatments are still urgently needed for the management of patients with SARS-CoV-2 infection, experiences in TCM is certainly worth learning. Fighting against current epidemics also provide an opportunity to test the true value of TCM in treating emerging contagious diseases. Randomized, double-blind and placebo-controlled studies is the best way to provide the most reliable evidence for a therapy, including TCM. It is encouraging that the controlled clinical studies to evaluate the efficacy of TCM in the treatment of SARS-CoV were conducted and reported. However, the most of these studies were found to be poorly designed and the results could lead to potential biases in evaluating the effectiveness of TCM treatment [13]. Hopefully, current clinical study to evaluate the effect of TCM on COVID-19 will use more strict protocols, concealment of allocation, and double-blinding, in order to ensure the compliance of international acceptable standards. Furthermore, standardized products of TCM, rather than self-prepared formulations, should be used in clinical study. Experiment study may be able to elucidate the mechanism underlying the therapeutic effect of TCM in the treatment of COVID-19. The further study of TCM may lead to the identification of novel anti human coronavirus compounds that may eventually prove to be useful in the treatment of SARS-CoV-2 or other emerging fatal viral diseases as conventional therapeutic agents.
The safety of TCM in the treatment of emerging coronavirus diseases was not included in the observation on SARS patients [13]. It was reported that some herbs used in TCM contain nephrotoxins and mutagens [108], while the toxicological features of the most of Chinese herbal medicines remain to be fully understood [109]. Furthermore, herbs used in TCM can mimic, or magnify, or oppose the effect of conventional medicines [110]. Thus, the safety of TCM used in treatment of emerging coronavirus infections should be carefully evaluated. It is particularly important to avoid toxicity or interfere with the efficacy of conventional treatment caused by herb-drug interaction.