A Single Centre, Prospective, Randomized, Open Labelled Clinical Study to Evaluate the Effectiveness of Siddha Poly Herbal Formulation, ViproTM, towards the Management of Uncomplicated Respiratory Infection

1Department of Pharmacology, Chettinad Hospital & Research Institute, Chettinad Academy of Research and Education, Kelambakkam, Chennai-603103, Tamil Nadu, India. 2Department of Physiology, Chettinad Hospital & Research Institute, Chettinad Academy of Research and Education, Kelambakkam, Chennai-603103, Tamil Nadu, India. 3Scientific and Academic advisor, International Institute of Biotechnology and Toxicology, Padappai, Kanchipuram-601301, Tamil Nadu, India. *Corresponding author E-mail: drarunvp@gmail.com

With the advent of worldwide SARS-CoV-2 pandemic and the desperation of humankind, to find a cure or a relief from the COVID-19 morbidity and to avoid mortality, especially the pharmaceutical and healthcare centers globally have been venturing various treatment options such as vaccines, drug combinations, and then alternative medicines such as AYUSH products in India.
With that purpose, 'Vipro TM ' has been developed and formulated based on the traditional system of medicine, the Siddha herbal alternatives. The product contains ten plant products as crude extracts based on the Materia medica of the Siddha literature and it is aimed to alleviate the respiratory implications of the patients, supposedly a COVID-19 infected or asymptomatic to it or any other common respiratory infections, and also as a prophylactic approach for the people who might get related respiratory infections.
The traditional medicinal ingredients of the product processed with essential oil from Cocus nucifera L, as base have been scientifically proven to ward off respiratory infectious diseases 1  A preclinical acute oral toxicity study in Wistar rats, Rattus norvegicus, was conducted as per the OECD guideline 423 with Vipro TM and it was observed that the formulation was safe in animals up to the dose of 2000 mg/kg as a limit dose with a cut off value of 5000 mg/kg body weight. Therefore, it is classified as Category 5 as per the Globally Harmonized System of Classification and Labelling of Chemicals (GHS). When it was converted to human equivalent dose by applying rodent to human conversion factor, 322.5 mg/kg body weight, which provided wide safety index for the clinical trial dose. Further the poly herbal product was formulated at VIMAC, a World Health Organization (WHO)-certified GMP facility, Chennai  Antimicrobial in nature and helps to maintain throat health [2] 2 Curcuma longa L Turmeric Tuber, 5 Rich in anti-oxidant, antimicrobial and helps to fight viral load [3] 3 Citrus lemon L Lemon Fruit, 10 Rich in vitamin C and helps to fight cough, flu and cold [4] 4 Cocus nucifera L Coconut Base oil Rich in antioxidant [5] 5 Allium sativum L Garlic Seed, 10 Antioxidant and helps to builds immunity [6] 6 Plectranthus amboinicus Lour Citrus Fruit, 10 Expectorant , helps to recover from cold and cough [7] 7 Momordica charantia L Bitter melon Pod, 30 Helps build immunity [8] 8 Piper nigrum L Pepper Seed, 5 Helps build immunity against infections [9] 9 Cinnamomum verum J.Presl. Cinnamon Bark, 5 Rich in antioxidant and antipyretic [10] 10 Zingiber officinale Rosc.
Ginger Tuber, 10 Antimicrobial properties and helps in build immunity [11]

Fig. 1. Participant flow diagram
Vipro TM in the management of uncomplicated respiratory infection including common cold with / without fever, flu like respiratory infection and bacterial respiratory infection. The patients, investigators and statisticians were not blinded. Simple random sampling was applied to all eligible subjects followed by random assignment of numbers between treated and control in each arm to ensure equal distribution of subjects.
The study was conducted in a tertiary care hospital in South India. 60 patients who fulfilled the selection criteria were enrolled in the study, after obtaining informed consent and they were grouped as per the treatment protocol defined into three as follows.
G r o u p 1 : S t a n d a r d t r e a t m e n t (symptomatic management with antipyretics and / or antihistamines and / or nasal decongestants and / or Levofloxacin and / or cough syrups for duration of 3 to 5 days as decided by the treating physician) Group 2: Liquid, oral, poly herbal formulation 'Vipro TM ', one teaspoon (20 drops) of formulation, mixed in a glass of water, mixed thoroughly and swallowed after food for 7 days, for four times a day, morning, afternoon, evening and night.
Group 3: "Standard Treatment + Vipro TM " combination was advised as in group 1 and 2 Selection criteria Inclusion Criteria 1. Age >18 years <60 years, both male and female; 2. Having uncomplicated respiratory infections, at least for less than 5 days, diagnosed with clinical symptoms and signs of fever, myalgia, rhinitis, sore throat, throat pain, cough, expectoration and head ache 3. Consenting to participate in the study and sign the informed consent Exclusion criteria 1. Patients with uncontrolled co-morbid conditions like Diabetes mellitus, Hypertension and Bronchial asthma 2. Patients with Lower respiratory tract infections, Chronic Bronchitis, Chronic obstructive airway problems 3. Patients with significant Cardiovascular, and Throat / Nasal swab for bacterial culture and sensitivity After the baseline assessment, the subjects were randomly provided with any one of the treatments as detailed above for groups 1, 2 and 3.

Follow up assessment (days 1 to 7)
Telephonic follow up (days 1 to 7) -Reminder for medication intake (daily once), adverse events (daily once), clinical symptoms for improvement / worsening (daily once), body temperature and constitutional symptoms (daily once) Physical follow up (On days 4 and 7) -Checking medication compliance, blood pressure, pulse, SpO2, respiratory rate, body temperature, constitutional symptoms, adverse events, general and systemic examination, clinical signs and symptoms During follow up -Complete blood count (with 5 ml of blood drawn) and Throat / Nasal swab for culture and sensitivity on day 7.
If the participants in group 2 did not show improvement in 48 hours, they were to be provided standard treatment from day 3. If the subjects were found to deteriorate with the treatments administered, they were to be withdrawn from the study and suitable alternate treatment was to be provided.
The subjects who experienced AE (Adverse Event) / SAE (Serious Adverse Event), were to receive treatment at free of cost till the event subsided.
Composite measure of Constitutional symptoms -The seven constitutional symptoms (fever, myalgia, rhinitis, sore throat, throat pain, cough and head ache) were given a score of each 1 in case of having these symptoms and each 0 in case of not having these symptoms. The scores of every subject was added at baseline, day 4 and day 7 to get the composite measure of constitutional symptoms. The reduction in the score from baseline to day 4 and 7 was considered for primary outcome.

Statistical Analysis
The analysis was carried out in ITT (Intention to treat) population and the interpretations and conclusions were made using ITT population.
Among the demographic parameters, gender was analysed using Chi square test and the remaining parameters were analysed using oneway ANOVA. The vital parameters were analysed using repeated measures ANOVA within groups and one-way ANOVA between groups.

(20%)
The blood parameters were analysed using paired t test within groups and one-way ANOVA between groups. The composite measure of constitutional symptoms was analysed using Friedman test within groups and Kruskal Wallis test between groups. The proportion of patients with adverse events was analysed using Chi square test between groups.

RESULTS
Out of 60 subjects who were randomized to one of the three treatment groups, 58 completed the study and there were 2 drop outs due to 'lost from follow up'. The participant flow diagram has been depicted according to the CONSORT (Consolidated Standards for Reporting Trials) guidelines in figure 1.
Among the subjects enrolled, 36 were males and 24 females. None of the subjects had significant co-morbid conditions, though one subject had hypertension in group 3 and one subject diabetes mellitus in group 2, their clinical condition was stable and were included in the study.
The subjects were followed up effectively by telephonic communication and the medication reminders were precisely given and hence the drug compliance was more than 90% in all the subjects across three groups. All the 58 subjects qualified for analysis of data as ITT population (group 1-19, group 2-19 and group 3-20 subjects).

Demographic profile
There was no statistically significant difference among the three groups for age, height, weight and BMI. The proportion of males was higher in group 1 and 2 compared to group 3 (p -0.03, Chi square test), but it does not have any clinical significance.

Vital parameters
Blood pressure, Pulse, SpO2 and Respiratory rate were within the acceptable limits during baseline, on day 4 and day 7 and there was no clinically significant differences or variations observed, though few parameters showed statistical significance during analysis.

Body Temperature
The body temperature at baseline and on day 4 and 7 during follow up was analysed in terms of absolute body temperature and the proportion of patients who were febrile. The reduction in body temperature was observed in all groups, from baseline to day 4 and day 7. The reduction was significant in group 1 and 3 (repeated measures ANOVA, p value < 0.05) whereas in group 2, the reduction was not statistically significant (repeated measures ANOVA, p >0.05), though the body temperature remained normal. Comparative analysis of the body temperature among three groups showed that the reduction is highly significant in group 1 (One-way ANOVA, p <0.05).
The proportion of patients who were febrile at various time points showed that the number of patients who were febrile at the time of enrollment was 15 in group 1 (78.94%), 1 in group 2 (5.26%) and 7 in group 3 (35%). All the patients became afebrile on day 4 and remained afebrile on day 7. The proportion of patients who had fever during baseline was significantly high in group 1 compared group 2 and 3 (p -0.00001, Chi square test).

Constitutional symptoms
These include myalgia, rhinitis, sore throat, throat pain, cough and head ache other than fever. These symptoms gradually improved in all groups and on day 7, 50 subjects had none of these symptoms. In group 1, one subject had cough on day 7. Five subjects in group 2 had constitutional symptoms such as head ache, sore throat and throat pain. Two subjects had symptoms like head ache and cough in group 3. Nevertheless, these symptoms improved from baseline and appropriate medical advice was given on day 7 to all these subjects. None of the subjects in this study exhibited worsening of symptoms or had any complications. The detailed data of symptomatic improvement in terms of proportion of subjects having constitutional symptoms is available in table 2.

Composite measure of constitutional symptoms
T h e m e a n c o m p o s i t e s c o r e f o r constitutional symptoms is 4.21, 4.00 and 4.00 in group 1, 2 and 3 respectively. It was reduced to 0.53, 1.26 and 0.55 in the respective groups 1, 2 and 3 on day 4 and further reduced to 0.05, 0.26 and 0.10 on day 7. The reduction in the composite score was statistically significant in all the groups (Friedman test, p<0.00001). Between group analysis showed that the reduction is highly significant in group 1 compared to group 2 and 3 (Kruskal Wallis, p<0.00001).
The analysis of composite measure of constitutional symptoms indicated that all the three treatments were effective and standard treatment was superior to other two treatments.

Complete blood count (CBC)
The analysis of CBC parameters did not show clinically significant changes in various parameters, though few statistically significant changes in WBC, platelets and Eosinophils were observed. There was a significant increase in WBC count in group 1 on day 7 compared to baseline (paired t test, p < 0.05). Platelet count increased in group 3 significantly (paired t test, p < 0.05) and this was significant compared to other two groups also (one-way ANOVA, p <0.05). There was an increase in Eosinophil count in group 2 (paired t test, P<0.05).
Out of 6 subjects who had positive throat swab during baseline in group 2, 4 subjects returned to normal flora on day 7. The other two subjects remained culture positive, with one subject having the organism Klebsiella and the other subject having Acinetobacter at baseline and got into Streptococcus pyogenes on day 7. Two subjects, in group 2, who were culture negative during baseline became culture positive with Staphylococcus aureus and Pseudomonas aeruginosa.
Three subjects who had culture positive during baseline returned to normal flora on day 7, in group 3. Three subjects who were negative during baseline became culture positive with one subject each having Klebsiella, Staphylococcus aureus and Acinetobacter on day 7.

Adverse events
Six subjects (10.34%) had adverse events. Three subjects had nausea, two subjects vomiting and one subject loose stools. These events were managed symptomatically and they all became normal in 24 hours. The study treatments were not interrupted due to adverse events. Among these AEs, one AE occurred in group 1 (5.26%) and group 2 (5.26%) each and 4 events in group 3 (20%). There were no serious adverse events.
Chi square analysis of proportion of patients having AEs indicated that there was no statistically significant difference among three groups (p-0.21) Palatable nature of Vipro TM 8 (42.10%) patients in group 2 and 7 (35%) patients in group 3 expressed that Vipro TM liquid formulation was bitter in taste even after diluting it in drinking water and it was difficult to consume it. This could be one of the reasons for less compliance observed in 6 patients in group 2 and 4 patients in group 3.
The summary of group wise demographic profile and baseline & follow up clinical data on day 4 and 7 including Blood pressure, Pulse, SpO2, respiratory rate, body temperature and constitutional symptoms are tabulated in table 1  and table 2 respectively.
The summary data of Blood parameters and bacterial culture of throat swab across groups in baseline and on day 7 is tabulated in Table 3.

DISCUSSION
This study which evaluated the effectiveness of Vipro TM in uncomplicated respiratory infection showed that Vipro TM had similar efficacy in reducing the constitutional symptoms as that of standard treatment. With regard to body temperature, patients in all the three groups became afebrile on day 4 and remained afebrile on day 7. The proportion of patients with fever during baseline was significantly high in group 1 compared to group 2 and 3 . Hence the statistical comparison of groups for reduction in the proportion of patients who are febrile will not be appropriate for assessment of efficacy.
Nevertheless, it is pertinent to note that all the patients were afebrile on day 4 and day 7. The mean body temperature is in febrile range only in group 1 and in other two groups it is in normal range during baseline. Hence the reduction in body temperature and its clinical significance in assessing the efficacy of interventions may not be appropriate.
One subject in group 1, five subjects in group 2 and two subjects in group 3 had constitutional symptoms at the end of treatment but these symptoms improved from baseline and they did not show any worsening of symptoms or any complications.
The composite score of constitutional symptoms was used to assess the efficacy of interventions. It was noted that all the three treatments were effective and standard treatment was found to be superior over the other two treatments. The addition of Vipro TM to the standard treatment resulted in more reduction of composite score compared to Vipro TM alone. The reduction observed in the combination treatment was numerically close to the standard treatment. But the advantage of adding Vipro TM to the standard treatment in routine clinical care for any additional benefit has to be explored further.
Complete blood count assessments did not show any clinically significant differences in all the three groups.
Throat swab bacterial culture showed that 4 subjects in group 2 and 3 subjects in group 3 had positive culture at the end of treatment. However, all these subjects who remained culture positive at the end of the study (Day 7) were not having any significant constitutional and clinical symptoms and they were managed according to the clinical judgement by the treating physician.
With regard to the safety, one subject in group 2 experienced mild gastrointestinal related adverse event and he became normal in next 24 hours. The treatment was not interrupted due to the adverse event and Vipro TM was found to be safe in all the subjects.
6 patients in group 2 and 4 patients in group 3 had less compliance with Vipro TM due to the bitter nature of the formulation.

CONCLUSION
This study evaluated the efficacy and safety the Siddha polyherbal formulation, Vipro TM in 58 patients of uncomplicated upper respiratory infection. Vipro TM has demonstrated efficacy in alleviating the clinical symptoms similar to standard treatment. With regard to safety, Vipro TM is associated with a few adverse events and all of them are minor in nature and subsided within 24 hours.