Effect of ArtemiC in patients with COVID‐19: A Phase II prospective study

Abstract Despite intensive efforts, there is no effective remedy for COVID‐19. Moreover, vaccination efficacy declines over time and may be compromised against new SARS‐CoV‐2 lineages. Therefore, there remains an unmet need for simple, accessible, low‐cost and effective pharmacological anti‐SARS‐CoV‐2 agents. ArtemiC is a medical product comprising artemisinin, curcumin, frankincense and vitamin C, all of which possess anti‐inflammatory and anti‐oxidant properties. The present Phase II placebo‐controlled, double‐blinded, multi‐centred, prospective study evaluated the efficacy and safety of ArtemiC in patients with COVID‐19. The study included 50 hospitalized symptomatic COVID‐19 patients randomized (2:1) to receive ArtemiC or placebo oral spray, twice daily on Days 1 and 2, beside standard care. A physical examination was performed, and vital signs and blood tests were monitored daily until hospital discharge (or Day 15). A PCR assessment of SARS‐CoV‐2 carriage was performed at screening and on last visit. ArtemiC improved NEWS2 in 91% of patients and shortened durations of abnormal SpO2 levels, oxygen supplementation and fever. No treatment‐related adverse events were reported. These findings suggest that ArtemiC curbed deterioration, possibly by limiting cytokine storm of COVID‐19, thus bearing great promise for COVID‐19 patients, particularly those with comorbidities.

ACE2 is highly expressed in the intestine, heart, kidney, lung and endothelium, where it cleaves angiotensin (Ang) I into Ang 1-9, which, in turn, is converted to Ang 1-7 by ACE2. 8,9 In addition, ACE2 generates Ang 1-7 directly from Ang II. 9 Interestingly, Ang II and Ang 1-7 exert opposing physiologic effects on the regulation of microcirculation and inflammation. 9,10 Specifically, while Ang II induces vasoconstriction, oxidative stress, inflammation, fibrosis and thrombosis, Ang 1-7 provokes, via its receptor, MasR, beneficial actions, including vasodilation, and anti-inflammatory, anti-fibrotic, anti-thrombotic and diuretic/natriuretic effects. 9,10 This might be of particular relevance to patients with heart failure, diabetes, pulmonary diseases and hypertension, that is clinical settings that are characterized by intense upregulation of ACE2. 1 The binding of SARS-CoV-2 to ACE2 and its subsequent internalization, depletes the cells of this enzyme and of Ang 1-7, conceivably contributing to the devastating cytokine storm characteristic of this disorder.
Thus far, there is no targeted effective pharmacological remedy for COVID-19. The therapeutic impact of pharmacological interventions such as hydroxychloroquine and Remdesivir are not evidencebased, and they are administered to critically ill patients with the lack of other valid therapeutic options. 11,12 Several studies support the use of short-term, low-dose corticosteroids in severely ill  patients. 13 In this context, a comprehensive study demonstrated that the use of dexamethasone in hospitalized patients with COVID-19 resulted in a lower 28-day mortality rate among those who were receiving either invasive mechanical ventilation or oxygen alone, but not among those who received no respiratory support. 14 In line with these findings, medical centres adopted administration of 6 mg dexamethasone daily, for up to 10 days, as a routine therapeutic protocol for patients with severe COVID-19. 15 Likewise, the multicentre CITRIS-ALI trial showed that intravenous administration of a moderate dose of ascorbic acid (vitamin C) was safe and reduced mortality among septic patients. 16 Interestingly, high-dose vitamin C infusion to patients with COVID-19 is therapeutically considered for COVID, although whether ascorbic acid can improve the prognosis of these patients is yet to be determined. 17 The development and approval of effective vaccinations or neutralizing antibodies concentrates may take up to years to reach developing countries, and there is no guarantee that they will be effective against evolving new SARS-CoV-2 lineages. 18,19 In addition, populations that are not eligible for vaccination, namely, paediatric populations, 20 vaccine hesitancy and unacceptance trend, 21,22 and populations with low vaccine efficacy, such as haemodialysis patients, and solid organ transplant recipients, 23-25 these barriers may be overcome by a simple, accessible, low-cost and effective intervention against all SARS viruses, that might restore the pulmonary and microcirculatory malfunction.
The current study examined the safety and tolerability of ArtemiC oral spray in hospitalized COVID-19 patients, as well as its efficacy in improving major symptoms of these patients. ArtemiC is comprised of artemisinin (6 mg/ml), curcumin (20 mg/ml), frankincense (15 mg/ml) and Vitamin C (60 mg/ml).
Inclusion criteria were confirmed SARS-CoV-2 infection (see Table 1), ≥18 years of age, hospitalized with COVID-19 symptoms of moderate stable or worsening severity not requiring intensive care unit (ICU) admission, but failing to respond to ongoing standard care, and ability to receive treatment by spray into the oral cavity. Patients on tube feeding or parenteral nutrition, in need of oxygen supply beyond use of nozzles or simple mask as per score 4 (Ordinal Scale for Clinical Improvement Score >4), with respiratory decompensation requiring mechanical ventilation, uncontrolled diabetes mellitus type 2, known autoimmune disease, pregnant or lactating, requiring admission to ICU in the course of the hospitalization at any time prior to completion of the recruitment to the study, or with any condition which, in the opinion of the principal investigator, would prevent full participation in this trial or would interfere with the evaluation of the trial endpoints, were not eligible to participate in the study.
Patients were monitored until day 15 or discharge from the hospital. Monitoring included daily physical examination, vital signs (blood pressure, pulse, weight, body temperature) measurements and haematology and biochemistry blood tests such as: complete Study products were labelled with randomization numbers at the manufacturing facility and shipped to the study sites.
Treatment was administered by the medical staff members in COVID-19 wards. All patients and researchers were blinded to the administered suspension, that is placebo or drug. Treatment involved administration of 1 ml spray (10 puffs) in the oral cavity, twice a day, at 12-h intervals on days 1 and 2 of the study, as an add-on treatment to SOC.
ArtemiC oral spray was given during the treatment session where, subjects received 1 ml oral spray (10 puffs), amounting to a total daily dose of 12 mg artemisinin, 40 mg curcumin, 30 mg frankincense and 120 mg vitamin C. The placebo oral spray is comprised of the same solvent (water), with no active ingredients. Both the active and control sprays were provided in a bottle containing 10 ml spray, which were stored at room temperature (see Table S1 for details concerning the drug preparation and ingredients).

Time to clinical improvement was defined as a ≤2 National Early
Warning Score 2 (NEWS2) maintained for at least 24 h. Time to clinical improvement in the active arm was compared to that of the control arm. Patient NEWS2 scaling is amended in supplementary file (Table S2). 26 The trial was registered in the NIH, ClinicalTrials.gov Identifier: NCT04382040.

| RE SULTS
Fifty patients with COVID-19 who were hospitalized in non-ICU wards were enrolled in the study; active treatment was administered to 33 patients and placebo to 17 patients. The demographic and baseline characteristics were similar across the two groups, as   While no inter-cohort differences were noted for mean body temperature, abnormal body temperature (>38.0°C or <36.0°C) was not measured after Day 9 (n = 1, 3.1%) in the active arm and after Day 12 in the placebo arm (n = 1, 5.9%).

| Secondary efficacy endpoints
In both treatment arms, all subjects showed within-range pulse and blood pressure levels by the end of the study. All ArtemiCtreated patients remained alert throughout the study period (NEWS2 subscale score: 0), whereas two placebo-treated patients suffered from new-onset disorientation during the study, which persisted for two days in one patient and 9 days in the other. It should be emphasized that the observed disorientation could be attributed either to the viral infection; however, we could not exclude the

| ArtemiC safety
In total, 17 adverse events (AEs) were reported in 9 patients receiving active treatment and 44 events in 7 patients receiving placebo treatment (  High oxidative stress is an additional complication of COVID-19 and contributes to the alveolar injury and thrombosis observed in this patient population. 47,48 In this regard, it was found that thiol levels are low in COVID-19 patients. 49 The role of oxidative stress in COVID-19 pathology is further supported by potential positive impact of oral and intravenous glutathione (GSH) and N-acetylcysteine (NAC) on the cytokine storm and ARDS in COVID-19 patients. 50,51 Likewise, ascorbic acid (vitamin C) and curcumin exert various pharmacological effects including anti-bacterial, anti-cancer, antiinflammatory, immuno-modulatory, anti-oxidant, anti-fungal, antimutagenic, and anti-viral activities, 52

| CON CLUS ION
This is the first clinical study addressing the safety and tolerability of ArtemiC oral spray and its efficacy in improving symptoms in hospitalized COVID-19 patients. ArtemiC treatment was associated with clinical improvement, improved SpO 2 levels and shorter duration of fever. These findings suggest that ArtemiC curbed deterioration, possibly by limiting the cytokine storm of COVID-19, and bears great promise for COVID-19 patients, particularly in those with comorbidities.

| Study limitations
Despite the encouraging results, the current study suffered from some limitations. These included the small cohort sizes, and failure to study possible mechanisms responsible for the beneficial effects of ArtemiC and to measure biomarkers of coagulation and cardiac and renal injuries. In addition, the relative contribution of each active ingredient remains unknown. Future studies are warranted to better understand efficacy and tolerability of the preparation, besides studying mechanisms of action of the products.

CO N FLI C T O F I NTE R E S T
The authors confirm that there are no conflicts of interest.

DATA AVA I L A B I L I T Y S TAT E M E N T
Data will be submitted upon request.