2.0 Study Design
The study was a double blind, randomized placebo-controlled clinical trial. The trial was conducted at Sri Sri college of Ayurvedic Science & Research Hospital, Sri Sri University, Cuttack, Odisha. The study was approved by the Institutional Ethics Committee, Sri Sri University (IEC Number- SSCASRH/IEC/001/21) and registered with CTRI No. CTRI/2021/08/036025. The duration of the study was from 1st to 25th September 2021. The participants were recruited during the entire study period, as and when they reported to the hospital. The intervention period for an individual patient was 10 days.
2.1 Participants
All patients who reported to inpatient (IPD) and outpatient (OPD) sections of COVID Care Centre at Sri Sri College of Ayurvedic Science & Research Hospital, Sri Sri University, Cuttack, Odisha, were invited to participate in the trial. Each patient with a confirmed symptomatic or asymptomatic case of COVID-19 was informed about the purpose of the clinical trial. Informed consent was obtained from those who wished to enroll in the study. Participants were informed about the insurance details, and were made aware that they could withdraw from the study at any time. Their written informed consent was obtained via a study specific proforma prepared for this trial, which included demographic information and baseline study parameters. 50 RT-PCR positive COVID-19 patients were enrolled after receiving their written consent. A total of 6 Patients were excluded from the study due to noncompliance. 25 patients in the NF2 arm and 19 patients in the placebo arm completed the clinical trial. The trial had to be terminated due to non-availability of COVID-19 patients.
2.1.1. Inclusion Criteria
- Asymptomatic or symptomatic RT-PCR positive mild to moderate COVID-19 cases (without comorbidities) as per the GOI norms
- History of fever of >98.60F
- Cough
- Dysponea (shortness of breath) or Tachypnea
- Patients of both genders between the ages of 18-77 years
- Indian Nationals
- Willingness to participate in the study with a written consent
2.1.2. Exclusion Criteria
- Not willing to give consent/ participate in the clinical trial
- Age less than 18 years or more than 75 years
- Patients with comorbidities such as uncontrolled hypertension, diabetes, thyroid disorder, Heart/ Lung/Liver/Renal disorder, moderate to severe anaemia / hematological disorders, Malignancy, Stroke: ischaemic stroke & intracerebral haemorrhage,
- Patients on immunosuppressive therapy
- Pregnant women or lactating mothers
- Any major surgery in the last six months or hospitalized for more than three days for any condition.
2.3 Intervention
Each patient was monitored for 10 days. Follow up assessments were conducted on day 5 and day 10. One nasal and one throat swab was obtained for RT-PCR on day 5 and 10 through an ICMR accredited laboratory. The patients were advised to inform the hospital staff immediately in case of any adverse events and/or aggravation of symptoms. Compliance with the treatment was assessed and subjects were counselled for dosage compliance in person.
2.3.1. NF2 preparation
NF2 also known as NOQ19. NF2 also is polyherbal formulation with 19 ingredients from 13 herbs. They are Ashwagandha (Withania somnifera) powder and extract, Bilwa (Aegle marmelos), Yashtimadhu (Glycyrrhiza glabra) powder and extract, Rasna (Pluchea lanceolata), Vasaka (Adhatoda vasica) powder and extract, Pippali (Piper longum), Haridra (Curcuma longa), Patha (Cissampelos pareira), Bhumiamla (Phyllanthus fraternus) powder and extract, Bhunimba (Andrographis paniculata) powder and extract, Saptaparna (Alstonia scholaris), Tulasi (Ocimum sanctum) and Guduci (Tinospora cordifolia) powder and extract. NF2 was procured from Sriveda Sattva Pvt Ltd, Bangalore (Sri Sri Tattva). The drug was licensed by Ministry of AYUSH, Govt. of India with the license number- AUS782. All the herbs which constituted NF2 were subjected to quality control. All the ingredients were blended with excipients followed by granulation, drying and compression. Once the tablet passed the QC tests, it was packed in bottles following standard procedure.
2.3.2. NF2 group
Participants enrolled in the NF2 arm were given the NF2 tablets. The dosage for NF2 arm was 2 tablets (500 mg each) thrice a day after food for 10 days.
2.3.3. Comparator Group
The placebo control group was provided the placebo tablets made of starch. They were packed in bottles identical to the NF2 bottles by Sri Sri Tattva. The dosage for placebo arm was also 2 tablets (500 mg each) thrice a day after food for 10 days.
2.3.4. Standard treatment
In addition to receiving NF2 or placebo, both groups received the standard treatment according to the government guidelines. The standard treatment included Azithromycin (500mg, once a day for 5 days) or Doxycycline (100mg, twice a day for 5 days), Levocetrizine (5mg once a day for 5 days), Vitamin C (10 days), Zinc (10 days) and Paracetamol (500mg, as required).
2.4 Outcomes
Clinical history was obtained from each participant enrolled in the study, followed by clinical examination and baseline investigations.
2.4.1. Primary Outcome
The primary outcome was the percentage of population turning RT-PCR negative by Day 5 and 10 in both study arms. One nasal and one throat swab was collected from each patient and subjected to the PCR analysis to identify the viral load in patients.
2.4.2. Secondary Outcomes
The secondary outcomes included the assessment of subjective parameters such as sore throat, cough, runny nose, shortness of breath, joint pain, fatigue, headache, loss of smell and loss of taste in both groups on Day 5 and Day 10 (Supplementary Table 1). The presence or absence of subjective outcomes was noted for each patient, in person, at each follow up time point, based on their baseline clinical history. Recovery or clinical improvement of patients was in par with the discharge policy provided by the Government of India.24 Observations of adverse events or side effects were also included in the secondary outcome. The assessment form has been provided for reference at the end of the paper as a supplementary table 1.
2.5. Sample size calculation
Based on the previous studies done on similar drugs, the study sample size was calculated to be 50 in each arm.25 But there was sharp decline in COVID cases at site so the enrollment had to close at 25 patients per arm.
2.6. Randomization and blinding
The study participants were allocated into different study arms with the help of a computer generated randomization code. The allocation was sequentially distributed. Since both NF2 and placebo were packaged in identical bottles, the participants were blinded to the respective intervention. The participants, data collector and the laboratory technician were blinded to the study group allocation.
2.7. Statistical analysis
The baseline characteristics of both study groups were reported as proportion/ mean (SD). Data analysis was conducted using the Intention To Treat (ITT) approach. The categorical variables were listed as number and percentage (%). The quantitative data was presented as the means ± SD. The data normality was checked using Kolmogorov-Smirnov test. In cases where the data was not normal, non-parametric tests were used. The quantitative variables, not normally distributed in nature, were analyzed using the Mann-Whitney Test (for two groups) and Independent t test was used for comparison of normally distributed data between two groups. Paired t test/Wilcoxon signed rank test was used for comparison across follow up. The variables which were qualitative in nature were compared and analyzed using Chi-Square test. If any cell had an expected value of less than 5, then Fisher’s exact test was used. The data entry was done in the Microsoft EXCEL spreadsheet and the final analysis was done with the use of Statistical Package for Social Sciences (SPSS) software, IBM manufacturer, Chicago, USA, version 2.0. For statistical significance, p value of less than 0.05 was considered statistically significant. (Fig 1)