Analysis on the compatibility rules and mechanism of formulae treatment for COVID-2019 based on the TCM inheritance assistance system and network pharmacology

Zi-Tong Fu,Jia-Xin Huang,Teng-Fei Bai,Guo-Wei Zhang*

1College of Chinese Medicine,Hebei University,Baoding 071000,China.

Abstract Background:On December 8,2019,Wuhan City,Hubei Province,a new type of coronavirus disease 2019(COVID-2019) was firstly discovered,and COVID-2019 spread rapidly in China.The number of confirmed cases in various provinces and cities rose sharply in China.In clinical treatment,Chinese medicine treatment showed significant efficacy.Since the outbreak,the National Health Commission (NHS) of China has issued seven editions of the “Pneumonitis Diagnosis and Treatment Program for COVID-2019”,at the same time,most provincial health boards and the Chinese Medicine Administration had also released information on the prevention and control scheme of COVID-2019 by Chinese medicine.The purpose of this study is to explore the compatibility rules of the main drugs in the prescription and the potential mechanism on COVID-2019 pneumonia,in order to provide reference for clinical research and new drug development of COVID-2019.Methods:This article uses the TCM inheritance assistance system and network pharmacology BATMAN-TCM online analysis system to collect and summarize the national “Pneumonitis Diagnosis and Treatment Program for COVID-2019 (trial version sixth)” and formulae for adult treatment from the TCM prevention program of 23 provinces and cities.Results:We found that the most formulae for the treatment of COVID-2019 were modified on the basis of Maxing Shigan decoction and the top 5 high-frequencyn drugs are Xingren (Armeniacae semen amarum),Mahuang (Ephedrae herba),Gancao(Glycyrrhizae radix et rhizoma),Shigao (Gypsum fibrosum),and Haungqin (Radix scutellariae).High frequency traditional Chinese medicines are mainly used for relieving the symptoms,clearing away heat,eliminating dampness,resolving phlegm,relieving cough and asthma,promoting water and dampness,and tonifying deficiency.Warm medicine and bitter medicine are the most frequently used drugs in four Qi attribute and five flavor attribute,respectively.Most of drugs are belong to lung,stomach and spleen channel.Mahuang (Ephedrae herba),Xingren(Armeniacae semen amarum),Gancao (Glycyrrhizae radix et rhizoma),Shigao (Gypsum fibrosum),Cangzhu(Atractylodis rhizama) and Huoxiang (Pogostemonis herba) are the core drugs for treating COVID-2019.The TTD disease enrichment,target and signal transduction pathways of the six drugs showed that pneumonia and asthma were most closely related to COVID-2019.And the inflammatory reaction-related pathways may be the main pathways through which these drugs function.Conclusions:The modified Maxing Shigan decoction is the main prescription for the treatment of COVID-2019.The Xingren (Armeniacae semen amarum),Gancao (Glycyrrhizae radix et rhizoma),Shigao (Gypsum fibrosum),Cangzhu (Atractylodis rhizama) and Huoxiang (Pogostemonis herba)have certain theoretical and experimental basis for the treatment of COVID-2019 through network pharmacology analysis,but further experiments are needed to verify the effects.

Key words:COVID-2019,TCM inheritance assistance system,Network pharmacology,Maxing Shigan decoction,Compatibility rules

Background

Since December 2019,the coronavirus disease 2019(COVID-2019) cases have been diagnosed in Wuhan,Hubei.With the spread of the disease,many cases have been found in various provinces and cities in China.The main clinical manifestations of COVID-2019 are fever,dry cough and fatigue.At present,the COVID-2019 has been included in the infectious diseases of class B as stipulated in theinfectious disease prevention and control law of the People's Republic of Chinaas an acute respiratory infectious disease.As the pathogenic novel coronavirus infects humans for the first time,there is no specific antiviral drug.Traditional Chinese medicine (TCM) is widely used for the treatment of COVID-2019 on the basis of modern medicine in China.However,it is difficult to assess the long-term safety and effectiveness of clinical treatment of Chinese medicine [1–2].

Xia Wenguang [3] et al.retrospectively analyzed in 52 patients with COVID-2019 and concluded that the cure rate of the COVID-2019 treated by integrated traditional Chinese and Western medicine was higher than that of the western medicine only group.According to the observation of clinical data,the team of academician Zhang Boli found that the combination of TCM and Western medicine can shorten the disappearance time of clinical symptoms and the recovery time of body temperature,and improve the CT image improvement rate and clinical cure rate [4].It can be seen that TCM has shown remarkable curative effect for COVID-2019.The “Pneumonitis Diagnosis and Treatment Program for COVID-2019(trial version sixth)”was released by the National Health Commission (NHS) of China and the State Administration of TCM in February 19,2020.Up to February 26th,the TCM prevention or control scheme for COVID-2019 was issued in 25 provinces and cities such as Beijing,Tianjin and Hebei provinces [5–29].The scheme in Shandong [17] and Henan Province [23]is TCM prevention plan rather than prevention and control program in other 23 provinces or cities.In this study,we summarized the formulae from the“Pneumonitis Diagnosis and Treatment Program for COVID-2019(trial version sixth)”and TCM prevention or control scheme in 23 provinces and cities to analyze the compatibility rules and mechanisms of action of core drugs for COVID-201.

Materials and methods

Prescription sources

The prescriptions are from the national "Pneumonitis Diagnosis and Treatment Program for COVID-2019(trial version sixth)"and the TCM prevention or control scheme in 23 provinces.

Data Screening

Inclusion criteria.Prescriptions for treatment period;Detailed drug composition and dosage; The prescription is oral decoction or pill.

Exclusion criteria.Non treatment period prescriptions,such as prevention prescriptions,medical observation prescriptions and recovery prescriptions; Non ordinary adult treatment prescriptions,such as children’s treatment prescriptions,pregnant women’s treatment prescriptions; The prescription that is used only but not known.

Standardizing name of Chinese medicine.According to the 13th Five-Year Plan,the 10th undergraduate teaching material,the names of Chinese medicines were standardized one by one.For example,gypsum and raw gypsum are input into raw gypsum and Yiren is entered into Coix seed.

Prescription Check and Entry.The included prescriptions were input into the TCM inheritance assistance system.Two people cooperated to input,one for input and one for check,so as to ensure the accuracy of input data.

Prescription Analysis.By the “data analysis” of the TCM inheritance auxiliary platform,we analyzed the drug frequency of included prescriptions.In the“statistical report” system,the properties,flavors,and channel of drugs were arranged in descending order and exported.These drugs with frequency ≥ 20 were classified by hand,and the commonly used drugs were summarized and sorted out on the basis of the selected prescriptions.

Core Drug Analysis.The core drugs were entered into the BATMAN TCM (http://bionet.ncpsb.org/batmantcm/) online analysis system.The score cutoff was set to 80,and the adjustedPvalue was set to 0.01.TTD disease enrichment,targets of action and KEGG pathway analysis were carried out to in BATMAN TCM.Then we use the software of Cytoscape (3.7.1)to construct disease-target network and KEGG pathway-target network for visualization.

Results

Drug frequency analysis

According to the above screening criteria,117 prescriptions with 202 Chinese medicines were screened.There are 17 kinds of Chinese medicines used more than 20 times,and the top 5 are Xingren(Armeniacae semen amarum),Mahuang (Ephedrae herba),Gancao (Glycyrrhizae radix et rhizoma),Shigao (Gypsum fibrosum)and Huangqin (Scutellariae radix) (Table 1).

The properties,flavors,and channel of drugs

Warm drugs and bitter drugs are the most frequently used drugs in the four properties and five flavors nature.The proportion of warm drugs and bitter drugsis 46.16% and 37.16%,respectively.The channels are mostly belonging to lung,stomach and spleen meridians which accounted for 23.40%,17.86% and 17.16%,respectively (Table 2).

Table 1 Chinese medicines used for the treatment of COVID-2019 with frequency ≥ 20

Efficacy classification of high frequency drugs

According to the classification results,the drugs used more than 20 times in the treatment period for COVID-2019 are mainly for relieving the symptoms,clearing away heat,resolving dampness and phlegm,relieving cough and asthma,promoting water and dampness,and tonifying deficiency (Table 3).According the analysis of high-frequency drugs and efficacy classification,we found that most formulae for the treatment of COVID-2019 are modified on the basic prescription called Maxing Shigan decoction.At the same time,most provinces and regions used Maxing Shigan decoction combined with drugs with the effects of clearing dampness to treat COVID-2019,of which Cangzhu (Atractylodis rhizama) and Huoxiang (Pogostemonis herba)were the most frequently used,as shown in Table 4.

Analysis of the potential mechanism of Maxingshigan decoction combined with Cangzhu(Atractylodis rhizama) and Huoxiang (Pogostemonis herba) in the treatment of COVID-2019 based on BATMAN-TCM

Analyze the mechanism of compatibility of Mahuang (Ephedrae herba),Xingren (Armeniacae semen amarum),Shigao (Gypsum fibrosum),Gancao(Glycyrrhizae radix et rhizoma), Cangzhu(Atractylodis rhizama) and Huoxiang (Pogostemonis herba).The disease enrichment and KEGG pathway analysis of Mahuang (Ephedrae herba),Xingren(Armeniacae semen amarum),Shigao (Gypsum fibrosum),Gancao (Glycyrrhizae radix et rhizoma),Cangzhu (Atractylodis rhizama)andHuoxiang(Pogostemonisherba) were obtained in BATMAN-TCM.There are 297 kinds of diseases and 12 kinds with potential target ≥ 8 (Table 5).There are151 signal pathways of these 6 drugs,of which 29 pathways have potential targets ≥ 10 (Table 6).The enriched diseases of inflammation and asthma are related to COVID-2019.

Table 2 Frequency distribution of property,taste and meridial distribution of herbs in the treatment of COVID-2019

Construct disease target and KEGG pathway target visualization network diagram.The selected diseases and targets above were imported into the software of Cytoscape (3.7.1) to construct disease-target and KEGG pathway-target network for visualization.Disease-target network includes 100 nodes,150 lines,red diamond for diseases and blue rectangle for targets(Figure 1).KEGG pathway-target network includes 285 nodes,624 lines,pink rectangle for pathways and blue rectangle for targets (Figure 2).

Table 3 Classification of efficacy of herbs for the treatment of COVID-2019 with frequency ≥ 20 times

Table 4 Statistics of Maxing Shigan decoction and clearing-dampness drugs

Table 5 Enrichment analysis of compatible diseases of Mahuang (Ephedrae herba),Xingren (Armeniacae semen amarum),Shigao (Gypsum fibrosum),Gancao (Glycyrrhizae radix et rhizoma),Cangzhu (Atractylodis rhizama),and Huoxiang (Pogostemonis herba)

Table 6 KEGG pathway analysis

Table 6 KEGG pathway analysis (continued)

Table 6 KEGG pathway analysis (continued)

Table 6 KEGG pathway analysis (continued)

Discussion

The COVID-2019 belongs to the category of epidemic disease in TCM theory.The patients are susceptible to the epidemic.This disease is located in the lung,and the basic pathogenesis is “wet,heat,poison,stasis”[31].Zhang Yunfei et al.[32] believed that the pathogenesis of COVID-2019 is that the toxic pathogen invades the lung and diarrhea occurs due to carrying heat; the lung qi fails in ventilating and descending,resulting in water and dampness retention.Pathogenic disease is the root and pathogenic dampness is the pathological product.When evil has entered,keep the pathogenesis in mind,and cure the evil to go out,you will get satisfactory curative effect[33].The TCM inheritance assistance system is an organic combination of computer science and TCM,using methods and techniques such as artificial intelligence,data mining,network science and other disciplines to realize the functions of disease information,syndrome information,TCM information,prescription information,medical records and related information collation and analysis [34]; network pharmacology is a subject,which construct and integrate the multi-level network system of"disease-gene-target-drug",through the integration of system biology,network biology,computer biology,and more Pharmacology,molecular pharmacology,molecular dynamics and other multidisciplinary technical contents.The subject is consistent with the synergistic characteristics of "multi-component,multi-target,multi-path" of TCM compound [35–36](two documents).This article uses the TCM inheritance assistance system (v2 .5) combined with the BATMAN-TCM online analysis system for 117 prescriptions in the “Pneumonitis Diagnosis and Treatment Program for COVID-2019(trial version sixth)” and the TCM prevention and treatment plans for COVID-2019 in 23 provinces and municipalities .The analysis of the regularity and potential mechanism of action is beneficial to the clinical research of TCM in the treatment of COVID-2019.

The high-frequency Chinese medications used in the prescription for COVID-2019 are drugs for relieving exterior disorder such as Mahuang (Ephedrae herba)and Shengjiang (Zingiberis rhizoma recens); the heat-clearing herbs such as Shigao (Gypsum fibrosum),Huangqin(Scutellariaeradix),and Lianqiao(Forsythiae fructus); dampness-clearing herbs such as Huoxiang (Pogostemonis herba),Houpo (Magnoliae officinalis cortex),Cangzhu (Atractylodis rhizama),ang Caoguo (Tsaoko fructus); phlegm-relieving,antitussive and asthma-relieving drugs such as Xingren(Armeniacaesemenamarum) and Tinglizi(Descurainiae siemenlepid semen); Qi-relieving medicine such as Chenpi(Citrireticulataepericarpium); diuretics for eliminating dampness such as Fuling (Poria) and Yiyiren (Coicis semen); tonic deficiency medicine such as Gancao (Glycyrrhizae radix et rhizoma) and Renshen (Ginseng radix et rhizoma); deworming medicine such as Binlang(Arecae semen).Manual comparison analysis showed that the national “Pneumonitis Diagnosis and Treatment Program for COVID-2019(trial version sixth)” and TCM treatment plan in 19 provinces and cities such as Tianjin and Hebei Province used modified Maxing Shigan decoction.Among them,the national “Pneumonitis Diagnosis and Treatment Program for COVID-2019(trial version sixth)” and TCM treatment programs in 14 provinces and cities such as Shanxi and Liaoning provinces used Maxing Shigan decoction in combination with clearing dampness herbs.Cangzhu (Atractylodis rhizama) and Huoxiang (Pogostemonis herba) have been used the most frequently.It can be seen that the combination of Maxing Shigan decoction and Cangzhu (Atractylodis rhizama) and Huoxiang (Pogostemonis herba) is the core combinations for the treatment of COVID-2019.Maxing Shigan decoction is derived from “Treatise on Febrile Diseases”.In this prescription,Mahuang(Ephedrae herba) is warm and bitter,enters the lung meridian,has the effects of sweating,releasing the lungs,relieving asthma and diminishing swelling;Shigao (Gypsum fibrosum) is sweet and cold,has the effect of clearing heat and purging fire,and can clear lung heat without cooling when compatible with Mahuang (Ephedrae herba).Xingren (Armeniacae semen amarum) is bitter and lukewarm,has the effect of relieving asthma and lowering lung qi,which is synergistic with Mahuang (Ephedrae herba) and Shigao (Gypsum fibrosum).Gancao (Glycyrrhizae radix et rhizoma) is sweet and plain,enters the heart,lung,spleen,stomach meridian,has the effect of clearing away heat,detoxifying and reconciling various drugs,can produce saliva and quench thirst when compatible with Shigao (Gypsum fibrosum).Cangzhu (Atractylodis rhizama) is warm,pungent and bitter,has the effect of dryness,dampness and spleen.Huoxiang (Pogostemonis herba) is pungent and lukewarm,enters the lungs,spleen,stomach meridian,has the function of aromatizing turbidity,stopping vomiting and releasing the heat-relieving effect,and treat the surface and the inside at the same time[37–38].Combined use of various medicines can relieve the surface,clear the heat,declare the lungs,dehumidify,and expel evil.The components of ephedra acidic polysaccharide ESP-B4 can reduce the production of inflammatory factors induced by lipopolysaccharide.The mechanism is mainly that ESP-B4 can down-regulate the phosphorylation of MAPK induced by lipopolysaccharide,and reduce the release of inflammatory factors and cytokines by inhibiting the TLR4 signaling pathway [39].Ephedrine can relax bronchial smooth muscle and play an anti-asthmatic role [40].Through analysis experiments and the observation of the asthmatic rat model,Aobo et al.[41] suggested that amygdalin in Xingren(Armeniacae semen amarum) can cooperate with the component of Mahuang (Ephedrae herba) to prolong the incubation period of asthma in rats,enhance the effect of lowering gas and cough,and relieve asthma and expectoration.Zhou YX et al.[42] observed and analyzed that the Shigao (Gypsum fibrosum) has significant antipyretic and anti-inflammatory effects,and it is superior to Duanshigao (Gypsum ustum) and CaSO42H2O containing the same ingredients.Studies have shown that glycyrrhizic acid can reduce the activity of influenza virus polymerase,thereby inhibiting its replication,and glycyrrhetinic acid has obvious inhibition on the replication of coronavirus ; at the same time,licorice polysaccharides,glycyrrhizin and derivatives in licorice also have strong antiviral effects and can significantly inhibit viral replication;applying glycyrrhizic acid as a weak glucocorticoid-like drug to the patients with COVID-2019 accompanied by “pathological filling of alveolar mucus” can enhance the action of glucocorticoids and antagonize their adverse reactions[43–44].In summary,the combination of Maxing Shigan decoction with Cangzhu (Atractylodis rhizama)and Huoxiang (Pogostemonis herba) for the treatment of COVID-2019 has a certain theoretical and experimental basis.

Based on high-frequency drugs and prescription rules,Mahuang(Ephedraeherba),Xingren(Armeniacae semen amarum),Shigao (Gypsum fibrosum),Gancao (Glycyrrhizae radix et rhizoma),Cangzhu (Atractylodis rhizama),and Huoxiang(Pogostemonis herba) were selected to predict the potential mechanism of action for the treatment of COVID-2019 by BATMAN-TCM.Among the enriched TTD diseases,inflammation and asthma are most closely related to the COVID-2019.Related study shows that Maxing Shigan decoction can up-regulate the expression of Th1 cytokine IL-12,down-regulate Th2 cell secretion,and promote the expression of STAT4 in lung tissue,can effectively reduce the airway hyperresponsiveness of asthma model mice,and has the effect of inhibiting airway remodeling [45–46].It was found in the enrichment analysis of biological signal pathway of these six drugs inflammatory response pathways are important such as MAPK pathway and TRP pathway.Han Jingyan [47]has proved through rat model experiments that Maxing Shigan decoction can improve endotoxin-induced leukocyte adhesion,inflammatory factor release and inflammatory cell infiltration in lung tissue of lung microvessels in rats to improve pulmonary interstitial edema.Β-cineol and atractylenolide in Atractylodes can block the activation of human mast cells p38 MAPK,JNK and NF-κB [48–49].Huoxiang can inhibit the expression of TNF-Q,IL-10 and IFN-γ in serum,and its therapeutic effect on mice infected with influenza virus is closely related to this [50].In summary,the combination of these 6 medicines,Mahuang (Ephedrae herba),Xingren (Armeniacae semen amarum),Shigao (Gypsum fibrosum),Gancao(Glycyrrhizaeradixetrhizoma),Cangzhu(Atractylodis rhizama),and Huoxiang (Pogostemonis herba)may play a role by improving the related inflammatory response of COVID-2019.

In this paper,the TCM inheritance auxiliary platform and the BATMAN-TCM online analysis system are used to analyze the medication rules and potential mechanism of action of TCM in the treatment of COVID-2019.We found that the modification of Maxing Shigan decoction is the main prescription in the treatment of COVID-2019,which is often used in combination with clearing-dampness drugs.Maxing Shigan decoction with Cangzhu (Atractylodis rhizama)and Huoxiang (Pogostemonis herba) may play a role in improving the related inflammatory response of COVID-2019,but further basic experiments and clinical trials are needed to verify.The results of this paper are intended to provide directions and ideas for the clinical compatibility of TCM treatment of COVID-2019 and the development of new drugs.