Impact of different treatment modalities on immunity against COVID-19

Authors

Mohamed M. Gamaleldina* , Shaimaa M. Nashata

a Ph.D. researcher at Department of clinical pharmacy, Faculty of pharmacy – Beni-Suef university, Egypt [Dissertation Joint supervision with university of Arizona, USA].

Mohamed M. Gamaleldina* ([email protected])

Shaimaa M. Nashata ([email protected])

ORCID ID: https://orcid.org/0000-0001-5372-5337

*Corresponding author at: Tel.: +201110188554, E-mail addresses: [email protected] (Mohamed. M. Gamaleldin)

ORCID ID: https://orcid.org/0000-0002-5188-637X

Abstract

COVID-19 infections virus spread worldwide and impacts many countries with sever economical sequences. The effective antiviral medication or vaccination for the virus is unavailable till the present date and it takes months or years to discovery the effective treatment or test the efficacy of the discovered treatment. Based on these facts, the human immunity system against the virus may have an effective role to regulate the infection and reduce the mortality rate among the infected patients. This proposed research article aims to explore the available medication/ natural supplementation to boost the immunity system of the patients against the COVID-19 infections and reduce the mortality rate among infected patients. Methods: a proposed clinical trial will be carried out to investigate the effect of the different treatment modalities on the human immunity system against COVID-19 infection.

Keywords: COVID-19, coronavirus, pneumonia, immune system, inflammation, immune boosting interventions, oxidative stress, hemoglobin, Anti-oxidant, Chelation agent, immunoregulation, Lymphopenia, Antiviral, Antihypertensive, Antimalarial. Introduction:

Natural supplementations have many reported effects on the human health ranged from immunity boosting to effective antiviral effect. Omeg-3 as an example affect the human health by many mechanisms e.g. Anti-oxidant, immunity boosting agent. Moreover, Omega-3 exerts an antiviral effect on Flu 1 virus by inhibiting influenza virus replication . On the other hand, black seed supplementation exerts a chelation effect on sickle cell anemia patients and inhibits Human Heme Metabolism 2. Moreover, black seed exerts an antiviral effect on the replication of old coronavirus and the expression of TRP genes family 3. In addition, Omega-3 regulates the human immunity against bacterial and viral infections 4. During the past years, many natural sources exerts an antimalarial effect with perfect reported results 5.

Study Design:

Study Type Interventional (sequential Clinical Trial)

Estimated Enrollment 200 participants [20 patients every month]

Allocation Randomized Intervention Model Parallel Assignment Intervention Model sequential clinical trial Description Masking Double (Participant, Care Provider) Primary Purpose Treatment Official Title Impact of different treatment modalities on immunity against COVID-19 Actual Study Start Date April 20, 2020 Estimated Primary October 2020 Completion Date Estimated Study Completion November 2020 Date

Condition/diseases Intervention Phase

COVID-19 Omega-3 supplementation Phase 2

Oxidative stress Nigella sativa supplementation Phase 3

Lymphopenia Indian Costus supplementation

Elevated iron level Quinine pills

Anise seed capsules

DGL [Deglycyrrhizinated Licorice] capsules

Artemisinin capsules

Febrifugine capsules

Arms & interventions:

Arm Intervention/treatment Drug: Omega 3 Omega-3 supplementation (300-400mg EPA & 200-300mg DHA) per day for one month Experimental group: Omega-3 + Drug: Nigella Sativa Oil TQ + Costus Nigella sativa supplementation (1g black seed oil contain 1% thymoquinone) per day for one month Month 1

Drug: Indian Costus supplements

Drug: Omega 3 Omega-3 supplementation (300-400mg EPA & 200-300mg Experimental group: Omega-3 + DHA) per day for one month TQ + Quinine pills Drug: Nigella Sativa Oil Nigella sativa supplementation (1g black seed oil contain 1% thymoquinone) per day for one month Month 2 Drug: Quinine pills Quinine supplementation (1g Quinine) per day for one month Drug: Omega 3 Omega-3 supplementation (300-400mg EPA & 200-300mg DHA) per day for one month Drug: Nigella Sativa Oil Experimental group: Omega-3 + TQ + Nigella sativa supplementation (1g black seed oil contain Quinine pills + Anise seed capsule 1% thymoquinone) per day for one month Drug: Quinine pills Month 3 Quinine supplementation (1g Quinine) per day for one month Drug: Anise seed capsule Anise seed supplementation (450mg anise seed) per day for one month

Arm Intervention/treatment Drug: Omega 3 Omega-3 supplementation (300-400mg EPA & 200- Experimental group: Omega-3 300mg DHA) per day for one month + TQ + DGL Drug: Nigella Sativa Oil Nigella sativa supplementation (1g black seed oil contain 1% thymoquinone) per day for one month Month 4 Drug: DGL [Deglycyrrhizinated Licorice] 800 mg per day for one month.

Drug: Omega 3 Omega-3 supplementation (300-400mg EPA & 200- Experimental group: Omega-3 300mg DHA) per day for one month + TQ + Artemisinin Drug: Nigella Sativa Oil Nigella sativa supplementation (1g black seed oil contain 1% thymoquinone) per day for one month Month 5 Drug: Artemisinin Capsules Artemisinin supplementation (150g Artemisinin) per day for one month Drug: Omega 3 Omega-3 supplementation (300-400mg EPA & 200- 300mg DHA) per day for one month Drug: Nigella Sativa Oil Experimental group: Omega-3 + Nigella sativa supplementation (1g black seed oil TQ + Quinine pills + FEBRIFUGINE contain 1% thymoquinone) per day for one month Drug: Quinine pills Month 6 Quinine supplementation (1g Quinine) per day for one month Drug: FEBRIFUGINE capsule FEBRIFUGINE supplementation (1g FEBRIFUGINE per day for one month

Active Comparator: standard of care Device: mechanical ventilation for COVID 19 pneumonia Drug: hydroxychloroquine Drug: lopinavir/ritonavir tablets 10 patients will receive standard of Drug: oseltamivir care for COVID 19 pneumonia. Drug: chloroquine phosphate / . Hydroxychloroquine

Outcome Measures:

Outcome Description

Clinical improvement [ Time Frame: Time to Clinical recovery Day 30] Recovery rate from positive to % of patients returned to negative swaps of negative swaps [ Time Frame: 20 days] COVID-19 Fever to normal temperature in days [ Number of days for fever remission T=37.5°C Time Frame: 15 days] Remission of lung inflammation in CT Number of days to report lungs recovery in or X ray [ Time Frame: 30 days] chest X ray or CT Length of hospitalization Number of days for hospitalization PCR levels [ Time Frame: Day 10] Reduction of PCR levels > 50% in comparison with PCR levels at the admission Respiratory indexes [ Time Frame: on P O2/Fi O2 which reflects patients' oxygen the day 10 and 20 after enrollment] saturation C-reactive protein mg/L [ Time Frame: C-reactive protein milligrams per deciliter 25 days] correlated with inflammation Serum Ferritin ng/ml [ Time Frame: 25 Serum Ferritin Nanograms per milliliter days] correlated with iron overload and illness severity Lactic acid dehydrogenase U/L [ Time Lactic acid dehydrogenase unit per litter Frame: 25 days] correlated with illness severity leukocytes count μl [ Time Frame: 30 leukocytes in microliter correlated with days] mortality Lipid profile [LDL, HDL, TC] Mg/dl correlated with lipid peroxidation that linked to oxidative stress The total plasma antioxidant capacity Evaluate the antioxidant response against the free radicals produced in Covid-19 infection measured by ELISA

Inclusion and Exclusion criteria:

Inclusion criteria Exclusion criteria ≥ 15 years old; Pregnant or breast feeding symptomatic with respiratory or Hepatic failure Child- systemic symptoms Pugh C Positive nasopharyngeal swab for Negative swab test of COVID-19 SARS-CoV-2 CT imaging showing viral pneumonia Expected life is less than 24 hours; Temperature 38°C end-stage lung disease Respiratory rate < 25 /min oxygen saturation (pulse oximetry) >95%

Discussion:

The present research article explores the treatment efficacy on the human immunity system. A proposed randomized clinical trial will investigate the efficacy of different treatment modalities on the human immunity system against COVID-19 infection. The following are the proposed mechanism of actions of the proposed interventions against COVID-19 infection.

Mechanism of action of Omega-3:

Based on previous literature review, the omega-3 supplementation may exert the following clinical actions on pediatric sickle patients:

Anti-oxidant: the effect of omega-3 supplementation on oxidative stress status which is the main source of ROC that weak the immunity system. PUFAs in omega-3 supplements limits the excessive inflammation and improve the immune response by migration and activation of phagocytic cells and T-cells into infected cells, Then initiation of adaptive immune response by recognition of antigen by B-lymphocyte. Measuring of correlation clinical parameter in hospital as an indication of reduction of oxidative stress.

Correlation clinical parameters are: Lipid profile specifically LDL-C which has strong positive correlation with lipid peroxidation.

Total antioxidant capacity (TAC) will carried out to determine the antioxidant response against the free radicals produced in patients with COVID-19.

Omega-3 exert antioxidant effect on oxidative stress status that promote immunity.

Omega-3 act as immunoregulator

Based on previous literature review, the omega-3 supplementation may exert the following clinical actions on pediatric sickle patients:

Antiviral effect: the antiviral effect of omega-3 supplementation mediated through lipid mediators Protectin D1 that inhibits virus replication.

Mechanism of action of Thymoquinone [Nigella sativa supplementation]:

Based on previous literature review, the Nigella sativa supplementation may exert the following clinical actions on pediatric sickle patients:

Chelation agent: the effect of thymoquinone supplementation on iron overload status that induce oxidative stress which is correlated with weak immunity.

TQ exert its action on Fe+++ and Fe++ to reduce iron overload.

Correlation clinical parameters are: Total Iron Binding Capacity (TIBC) and Serum total iron that have strong positive correlation with lipid peroxidation in thalassemic patients.

Antihypertensive: TQ act as antihypertensive by reducing ACE activity.

Antioxidant: TQ act as anti-oxidant by preventing hemoglobin oxidation.

Mechanism of action of Quinine, Anise seed, Deglycyrrhizinated Licorice, Artemisinin, Febrifugine:

• Quinine pills: Natural antimalarial effect • Anise seed capsules: Natural antiviral effect as it is a precursor of oseltamivir medication. • Deglycyrrhizinated Licorice capsules: Natural antiviral, Anti SARS effect • Artemisinin capsules: Natural antimalarial effect • Febrifugine capsules: Natural antimalarial effect

Conflict of Interests:

None.

REFERENCES:

1. Morita, M., Kuba, K., Ichikawa, A., Nakayama, M., Katahira, J., Iwamoto, R., Watanebe, T., Sakabe, S., Daidoji, T., Nakamura, S., Kadowaki, A., Ohto, T., Nakanishi, H., Taguchi, R., Nakaya, T., Murakami, M., Yoneda, Y., Arai, H., Kawaoka, Y., Penninger, J.M., Arita, M., Imai, Y., 2013. The lipid mediator protectin D1 inhibits influenza virus replication and improves severe influenza. Cell 153, 112– 125. https://doi.org/10.1016/j.cell.2013.02.027

2. Liu, W., & Li, H. (2020). COVID-19: Attacks the 1-Beta Chain of Hemoglobin and Captures the Porphyrin to Inhibit Human Heme Metabolism. ChemRxiv, 1, 31. https://doi.org/10.26434/chemrxiv.11938173.v6

3. Ulasli, M., Gurses, S. A., Bayraktar, R., Yumrutas, O., Oztuzcu, S., Igci, M., Igci, Y. Z., Cakmak, E. A., & Arslan, A. (2014). The effects of Nigella sativa (Ns), Anthemis hyalina (Ah) and Citrus sinensis (Cs) extracts on the replication of coronavirus and the expression of TRP genes family. Molecular Biology Reports, 41(3), 1703–1711. https://doi.org/10.1007/s11033-014-3019-7

4. Husson, M. O., Ley, D., Portal, C., Gottrand, M., Hueso, T., Desseyn, J. L., & Gottrand, F. (2016). Modulation of host defence against bacterial and viral infections by omega-3 polyunsaturated fatty acids. Journal of Infection, 73(6), 523–535. https://doi.org/10.1016/j.jinf.2016.10.001

5. Mojab, F. (2012). Antimalarial natural products: a review. Avicenna Journal of Phytomedicine, 2(2), 52–62. https://doi.org/10.22038/ajp.2012.30