Abstract

   The outbreak of new infectious pneumonia caused by SARS-CoV-2 has posed
   a significant threat to public health, but specific medicines and
   vaccines are still being developed. Traditional Chinese medicine (TCM)
   has thousands of years of experience in facing the epidemic disease,
   such as influenza and viral pneumonia. In this study, we revealed the
   efficacy and pharmacological mechanism of Ma Xing Shi Gan (MXSG)
   Decoction against COVID-19. First, we used liquid
   chromatography–electrospray ionization tandem mass spectrometry
   (LC-ESI-MS/MS) to analyze the chemical components in MXSG and
   identified a total of 97 components from MXSG. Then, the intervention
   pathway of MXSG based on these components was analyzed with network
   pharmacology, and it was found that the pathways related to the virus
   infection process were enriched in some of MXSG component targets.
   Simultaneously, through literature research, it was preliminarily
   determined that MXSG, which is an essential prescription for treating
   COVID-19, shared the feature of antiviral, improving clinical symptoms,
   regulating immune inflammation, and inhibiting lung injury. The
   regulatory mechanisms associated with its treatment of COVID-19 were
   proposed. That MXSG might directly inhibit the adsorption and
   replication of SARS-CoV-2 at the viral entry step. Besides, MXSG might
   play a critical role in inflammation and immune regulatory, that is, to
   prevent cytokine storm and relieve lung injury through toll-like
   receptors signaling pathway. Next, in this study, the regulatory effect
   of MXSG on inflammatory lung injury was validated through transcriptome
   results. In summary, MXSG is a relatively active and safe treatment for
   influenza and viral pneumonia, and its therapeutic effect may be
   attributed to its antiviral and anti-inflammatory effects.

   Keywords: Ma Xing Shi Gan decoction, COVID-19, Traditional Chinese
   Medicine, immunomodulatory, antiviral
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Graphical Abstract.

   Study design:the workflow for the whole study

   [44]Graphical Abstract
   [45]Open in a new tab

Introduction

   The coronavirus disease 2019 (COVID-19) epidemic is a global public
   health crisis, with considerable mortality and morbidity exerting
   pressure on health care and the economy. Unfortunately, there are
   currently no drugs or vaccines available to treat specific antivirals
   ([46]Zumla et al., 2016; [47]Xie et al., 2020). The majority of
   patients infected with SARS-CoV-2 show symptoms of pneumonia, fever,
   dry cough, fatigue, and other symptoms such as myalgia, and diarrhea
   ([48]Henry and Vikse, 2020; [49]Stower, 2020; [50]Xiong et al., 2020).
   Like SARS-CoV, the spine (S) protein of SARS-CoV-2 enters human
   alveolar epithelial cells by binding the angiotensin-converting enzyme
   2 (ACE2) receptor ([51]Zhou et al., 2020). At low viral titers, the
   human immune response may be characterized by the antiviral response to
   type I interferon and the CD4^+ and CD8^+ T-cell response, leading to
   viral clearance. Severe infection and excessive immune-inflammatory
   response caused by high viral titer have been proved to be the leading
   cause of progression to acute lung injury (ALI), acute respiratory
   distress syndrome, respiratory and circulatory failure, and even death
   ([52]Chen et al., 2020; [53]Narasaraju et al., 2020; [54]Wang et al.,
   2020). Patients with COVID-19 exhibit pathogenesis; clinical
   manifestations are similar to the symptoms of SARS-CoV and H1N1
   infections. Therefore, although the pathogenesis of COVID-19 is poorly
   understood, the similar mechanisms of SARS-CoV and H1N1 can give us a
   great deal of information on the pathogenesis of SARS-CoV-2 infection
   to promote our recognition ([55]Li et al., 2020c).

   Based on clinical observation of COVID-19 and experience in treating
   SARS and H1N1, the guideline on diagnosis and treatment of COVID-19 has
   proposed that combines modern medicine with TCM in China ([56]Liu et
   al., 2012; [57]Li and Peng, 2013; [58]Dei-Cas et al., 2020). According
   to the Press Conference of the Joint Prevention and Control Mechanism
   of State Council, 74,187 people have used Chinese medicine in confirmed
   cases of COVID-19 in China. It accounted for 91.5% of the total cases.
   Clinical observation shows that the total effective rate of TCM has
   reached more than 90% ([59]National Health Commission of the People’s
   Republic of China, 2020). Ma Xing Shi Gan (MXSG) decoction, was the
   basic formula of three drugs and three formulas including Lian Hua Qing
   Wen capsules (LHQW), Jin Hua Qing Gan granules (JHQG), Qing Fei Pai Du
   decoction (QFPD), Hua Shi Bai Du decoction (HSBD), and Xuan Fei Bai Du
   decoction (XFBD) promulgated by China’s National Health Commission for
   the treatment of COVID-19. It has been applied to COVID-19 patients in
   both suspected cases and confirmed individuals with mild cases,
   moderate cases, severe cases, and critical cases. A previous study has
   demonstrated that MXSG exhibits similar antiviral activity to
   oseltamivir and broad-spectrum inhibitory activity in mice infected
   with influenza A virus ([60]Li et al., 2017; [61]Zou et al., 2018).
   This activity has also been confirmed in the LHQW and JHQG treatment of
   H1N1 patients ([62]Duan et al., 2011; [63]Wang et al., 2011). Also,
   MXSG can downregulate chemokines, inhibit inflammation response, and
   ameliorate the ALI in model rats ([64]Ma et al., 2014; [65]Fei et al.,
   2019). However, the overall understanding of the therapeutic effect and
   potential mechanisms of MXSG in the COVID-19 remains elusive.

   Here, we dissected the chemical components of MXSG by liquid
   chromatography–mass spectrometry (LC-ESI-MS/MS) and analyzed the
   intervention pathways of MXSG based on components detected through
   network pharmacology. At the same time, the therapeutic effect of MXSG
   on COVID-19 was explained through published articles, and the relevant
   regulatory mechanism was proposed. Then, in this study, the regulatory
   effect of MXSG on inflammatory lung injury was validated through
   transcriptome results. In summary, our study suggests that MXSG
   inhibits viral invasion, proliferation, and mitigation of virus-induced
   lung injury, which may be a key mechanism of its therapeutic effect on
   COVID-19. These results provide experience for the treatment of
   infectious diseases and lung injury.

Results

Characterization of Chemical Constituents in Ma Xing Shi Gan Decoction

   Representative total ion chromatograms obtained by LC-ESI-MS/MS are
   shown in [66]Figure 1. After peak integration, 126 peaks were detected
   as individual compounds. Based on the MetWare database and the
   published database of metabolite information, qualitative analysis was
   conducted on the primary and secondary spectrum data of mass
   spectrometry. As a result, 97 components were identified from MXSG. The
   compounds identified from MXSG were listed in [67]Supplementary Table
   S1, including 40 flavonoids, 18 phenolic acids, 16 alkaloids, 10
   terpenes, five lignans and coumarins, one quinone, and other types of
   compounds.

FIGURE 1.

   [68]FIGURE 1
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   Representative total ion chromatogram MXSG. (A) Positive mode. (B)
   Negative mode.

Characterization of Potential Therapeutic Targets of Ma Xing Shi Gan
Decoction

   The potential therapeutic target network of MXSG was presented in
   [70]Figure 2. We first collected the targets of compounds identified by
   LC-ESI-MS/MS. Among the 97 compounds detected, 54 corresponding targets
   were obtained through database retrieval, and a total of 204 targets
   were obtained after merging and deleting. Then, GO and KEGG enrichment
   analysis was performed on the target information ([71]Figure 2). In the
   GO enrichment analysis results, MXSG mainly played an intervention role
   by interfering with cellular processes and metabolic processes. The
   intervention mainly affects the cell membrane structure, and the main
   target molecules participate in the protein binding process and
   catalytic function. KEGG analysis showed that the role of MXSG was
   mainly to interfere with tumor-related pathways and viral
   infection–related pathways. The target information is in
   [72]Supplementary Table S2.

FIGURE 2.

   [73]FIGURE 2
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   Functional analysis of MXSG. (A) GO enrichment of related genes. (B)
   Top 20 pathways enriched by the KEGG method.

Efficacy of Ma Xing Shi Gan Decoction Against COVID-19 From Published
Research Evaluation

   MXSG is one of the most frequently used and valid prescriptions for
   COVID-19 prevention and control programs. It is the fundamental
   component of three drugs and three formulas, including LHQW, JHQG,
   QFPD, HSBD, and XFBD promulgated by China’s National Health Commission.
   We made a summary of MXSG and its extended formula formulation,
   effects, and clinical features ([75]Supplementary Table S3).

   And then, we made a summary of therapeutic effects of MXSG or its
   extended formula for SARS-CoV-2 or H1N1 infection. The results showed
   that MXSG was effective in treating influenza or viral pneumonia in
   both animal and clinical studies. The animal research involved three
   animal models of type A influenza virus infection, including BALB/c
   mice, KM mice, and WT mice. In the clinical studies, a total of 4,596
   cases patients with SARS-CoV-2 or H1N1 infection were involved,
   including clinical observation studies, prospective cohort studies,
   retrospective studies, double-blinded randomized control trials, and
   randomized double-blind positive controlled clinical trial studies
   ([76]Table 1).

TABLE 1.

   Efficacy evaluation of MXSG or its extended formula for influenza virus
   infection.
   Drug Therapeutic effects Methodology References