Radix Astragali and Radix Angelicae Sinensis in the Treatment of Idiopathic Pulmonary Fibrosis: A Systematic Review and Meta-analysis

Introduction There are many clinical studies in the treatment of idiopathic pulmonary fibrosis (IPF) with herbal medicine including Astragalus mongholicus Bunge, Radix Astragali (RA) and Angelica sinensis (Oliv.) Diels, Radix Angelicae Sinensis (RAS). These have obtained good curative effect. There is no systematic evaluation on the clinical efficacy of RA and RAS in patients with IPF. The aim of this systematic review and meta-analysis was to critically evaluate the current evidence of efficacy and safety of RA and RAS in IPF. Methods We searched the primary database for randomized controlled trial (RCT) of RA and RAS treating IPF. We assessed the quality of included studies using the Jadad rating scale and referred to the Cochrane Reviewer's Handbook for guidelines to assess the risk of bias. We extracted the main outcomes of included RCTs and a meta-analysis was conducted using the Cochrane Collaboration's RevMan5.3 software. Results Seventeen eligible RCTs were identified and made a systematic review and meta-analysis. Risk of bias and quality of included RCTs were carried out. The results of meta-analysis showed that total effective rate and traditional Chinese medicine syndrome effective rate were statistically significantly higher in the experimental group than the control group, main pulmonary function index, six minute walking distance and Borg scale questionnaire score were statistically significantly better in the experimental group than the control group and incidence of adverse reactions was statistically significantly lower in the experimental group than the control group. Conclusion RA and RAS are effective and safe in the treatment of IPF, which is beneficial to pulmonary function and exercise tolerance of these patients.

Introduction: There are many clinical studies in the treatment of idiopathic pulmonary fibrosis (IPF) with herbal medicine including Astragalus mongholicus Bunge, Radix Astragali (RA) and Angelica sinensis (Oliv.) Diels, Radix Angelicae Sinensis (RAS). These have obtained good curative effect. There is no systematic evaluation on the clinical efficacy of RA and RAS in patients with IPF. The aim of this systematic review and metaanalysis was to critically evaluate the current evidence of efficacy and safety of RA and RAS in IPF.

Methods:
We searched the primary database for randomized controlled trial (RCT) of RA and RAS treating IPF. We assessed the quality of included studies using the Jadad rating scale and referred to the Cochrane Reviewer's Handbook for guidelines to assess the risk of bias. We extracted the main outcomes of included RCTs and a meta-analysis was conducted using the Cochrane Collaboration's RevMan5.3 software.
Results: Seventeen eligible RCTs were identified and made a systematic review and meta-analysis. Risk of bias and quality of included RCTs were carried out. The results of meta-analysis showed that total effective rate and traditional Chinese medicine syndrome effective rate were statistically significantly higher in the experimental group than the control group, main pulmonary function index, six minute walking distance and Borg scale questionnaire score were statistically significantly better in the experimental group than the control group and incidence of adverse reactions was statistically significantly lower in the experimental group than the control group.

INTRODUCTION
Idiopathic pulmonary fibrosis (IPF) is a type of interstitial lung disease characterized as chronic, progressive and fibrotic, and its clinical manifestation is progressive aggravation of dyspnea, restrictive ventilation dysfunction and gas-exchange disorder, hypoxemia and even respiratory failure . The chest high-resolution CT (HRCT) or lung histology of IPF is characteristic of usual interstitial pneumonia (UIP) (Raghu et al., 2018). IPF is a rare disease, which is prone to the elderly. In Europe and North America, the incidence of IPF is about 2.8-9.3 per 100,000, and the epidemiological data in China is not much, but the incidence of IPF in recent years has increased significantly (Navaratnam et al., 2011;Huang et al., 2013;Hutchinson et al., 2015). IPF is currently incurable, and the clinical purpose is to delay the deterioration of lung function, improve the quality of life and delay the progress of the disease. At present, western medicine, such as antifibrotic drugs, has certain curative effect in the treatment of IPF, but due to the high price and some side effects, it is restricted in patient use (Lee et al., 2013). In recent years, the position of traditional Chinese medicine (TCM) in the treatment of IPF is becoming more and more important, and the clinical research and meta-analyses have shown that the herbal medicine treating IPF could improve the clinical symptoms, delay the reduction of the lung function, and improve the quality of life of the patients Chen et al., 2019;Wu et al., 2019). Many experiments have shown that the herbal medicine has the effects of improving the pathological and pulmonary function of bleomycin-induced IPF rats (Chen et al., 2016;Yu et al., 2018).
Herbal medicine is the main treatment of TCM, the collocation of monarch herbs and minister herbs is adjusted according to the common pathogenesis of patients with further prescription to adapt to the different pathogenesis of IPF. DangGuiBuXue Decoction has the history of nearly 800 years, and is composed of two commonly used Chinese herbal medicines of Astragalus mongholicus Bunge, Radix Astragali (RA) and Angelica sinensis (Oliv.) Diels, Radix Angelicae Sinensis (RAS), and has the effects of benefiting vital energy and promoting blood circulation . At present, based on the association rules of the literature, the treatment of IPF with TCM is mainly related to benefiting vital energy and promoting blood circulation, among which RA and RAS are the most common herbs for invigorating qi and activating blood (Ren, 2017;Huang et al., 2018). There are many experiments on the treatment of IPF, which manifest RA and RAS can improve pulmonary fibrosis in animal model (Liu, 2009;. Our recent research shows that RA and RAS in the treatment of IPF through the multi-target and multi-pathway were systematically discussed, which plays an important role in the clinical application . At present, there are few clinical studies on the treatment of IPF with RA and RAS only, but many clinical studies on the treatment of IPF used herbal medicine included RA and RAS as the main components and have obtained good curative effect (Sun, 2005;Wei and Qiang, 2007;Sun et al., 2008). There is no systematic evaluation report on the clinical efficacy of RA and RAS as the main components of herbal medicine in the treatment of IPF. The aim of this systematic review and metaanalysis was to critically evaluate the current evidence of effectiveness and safety on the use of RA and RAS in the treatment for patients with IPF.

Data Sources and Search Strategy
We searched the main English and Chinese databases from the establishment of the database to October 30, 2019. PUBMED, EMBASE, Science Citation Index (SCI), Cochrane Central Register of Controlled Trials, Chinese Biomedical Literature database (SinoMed), Chinese National Knowledge Infrastructure (CNKI), Wanfang Data and the Chongqing VIP database(CQVIP) were included.
The search term "pulmonary fibrosis" was combined with the following keywords respectively: "Astragali"; "Angelicae"; "DangGuiBuXue Decoction"; "DangGuiBuXue Tang"; "traditional Chinese Medicine"; "Chinese Medicine"; "herbal medicine". We also searched for these terms in titles and abstracts. When such data were not included in abstracts, if such data existed in the full text, the full-text paper was screened as well. We also checked references and citations of the identified studies manually to include other potentially eligible trials until no additional articles could be identified.

Inclusion and Exclusion Criteria
Inclusion criteria: (1) The study was designed as a randomized controlled trial (RCT); (2) The participants were in accordance with the diagnosis of IPF, which is in line with the Chinese Medical Association Respiratory Society issued guidelines for diagnosis and treatment or ATS/ERS/JRS/ALAT Clinical Practice Guideline; (3) Herbal medicine included RA and RAS was used in the experimental group; (4) The control group used conventional therapy without TCM therapy; (5) There were clear outcome measures.
Exclusion criteria: (1) Duplicated publications, the earlier published or the one with most complete information was included and the rest were excluded; (2) Animal experiments; (3) Case reports, reviews and abstracts; (4) Lack of data outcome measures to evaluate the effects.

Quality Assessment and Data Extraction
Using the Jadad rating scale (Higgins et al., 2011) and the Cochrane Reviewer's Handbook for guidelines, the quality and risk of bias of included studies were assessed (Higgins et al., 2011).
The scores were obtained by evaluating a RCT with three items describing randomization (0-2 points), blinding (0-2 points), and dropouts and withdrawals (0-1 points). One point was given for each term if these terms were mentioned in the study. If the method to generate the sequence of randomization or the method of blinding was described and appropriate, then 1 additional point was given, whereas 1 point was deducted if it was inappropriate. The quality scale ranges from 0 to 5 points. Higher scores indicate better reporting. It was divided into low quality less than 3 and high quality greater than or equal to 3 (Jadad et al., 1996).
We used the Cochrane classification of seven criteria to assess the risk of bias, which contained: random sequence generation, allocation concealment, patient blinding, assessor blinding, incomplete outcome data, selective outcome reporting and other risks of bias (Higgins et al., 2011).
Two reviewers independently extracted the information of data, which included: the first author, year of publication, number of patients in each group, major composition of TCM prescriptions, methods of intervention on experimental group and control group and outcomes.
All authors consulted the disagreement about the detail of study until it was resolved by consensus.

Statistical Analyses
The Cochrane Collaboration's RevMan5.3 software was used for systematic review and meta-analysis. Continuous data were expressed as mean difference (MD) with 95% confidence interval (CI). Dichotomous data were expressed as odds ratio (OR) with 95% CI. A test of heterogeneity was assessed by the Q test (P value and I²), which describes the percentage of variability in the effect and estimates the contribution of heterogeneity rather than by chance (Higgins and Thompson, 2002;Higgins et al., 2003). A significant Q-statistic (P < 0.10) indicated heterogeneity across studies. Studies with an I² statistic of less than 50% are considered to have no heterogeneity and those with an I² statistic of equal or more than 50% are considered to have heterogeneity. If no significant heterogeneity was detected, the fixed effects model was used as the pooling method; otherwise, the random effect model was considered to be the appropriate choice. We perform the funnel plot to determine publication bias when more than 10 studies are included in a meta-analysis. All reported probabilities (P values) were two-sided, and P< 0.05 was considered statistically significant.

Research Selection
A total of 4812 studies were retrieved through database searching and other sources. After removing duplication, 1424 studies had been retained. A total of 1346 obviously irrelevant studies were excluded after reading the title and the abstract, another 61 studies were excluded due to various reasons after reading the full text. Seventeen RCTs were included in the systematic evaluation (Sun, 2005;Wei and Qiang, 2007;Sun et al., 2008;Dong, 2010;Yang, 2010;Wang, 2011;Chen et al., 2012;Wu et al., 2012;Meng et al., 2016;Zhao et al., 2016;Jiang, 2017;Deng and Wang, 2018;Ma, 2018;Miao et al., 2018;Yang, 2018;Guo et al., 2019;Peng, 2019). The literature screening process and results are shown in Figure 1.

Description of Included Studies
Seventeen eligible RCTs (Sun, 2005;Wei and Qiang, 2007;Sun et al., 2008;Dong, 2010;Yang, 2010;Wang, 2011;Chen et al., 2012;Wu et al., 2012;Meng et al., 2016;Zhao et al., 2016;Jiang, 2017;Deng and Wang, 2018;Ma, 2018;Miao et al., 2018;Yang, 2018;Guo et al., 2019;Peng, 2019) were identified. Seventeen RCTs were all conducted in China and included 1211 patients. Two studies (Sun, 2005;Guo et al., 2019) were multicenter studies and others were single-center studies. One RCT (Peng, 2019) used the prescription of TCM only included RA and RAS and other RCTs used the prescription of TCM included RA and RAS as the main components. The control group included conventional western medicine treatment (CWMT), while prednisone tablets were used in a number of studies (Sun, 2005;Wei and Qiang, 2007;Sun et al., 2008;Dong, 2010;Yang, 2010;Wang, 2011;Jiang, 2017;Deng and Wang, 2018;Yang, 2018;Peng, 2019); prednisone tablets a nd cyclophosphamide tablets were used in three studies (Wu et al., 2012;Meng et al., 2016;Miao et al., 2018); acetylcysteine was used in two studies (Zhao et al., 2016;Ma, 2018); one study (Guo et al., 2019) used placebo granules; one study (Chen et al., 2012) only mentioned the use of CWMT. Basic features of included studies are outlined in Table 1, the composition of TCM prescriptions used in experimental group of each study are outlined in Table 2 and the quality control of TCM prescriptions are outlined in Table 3.
The main outcomes and results are outlined in Table 5.

Pulmonary Function Tests
The two studies (Zhao et al., 2016;Guo et al., 2019) that compared FVC included a total of 250 participants, 125 and 125 in experimental group and control group, respectively. The two studies had heterozygosity (heterozygosity test, Chi² = 4.82, P = 0.03, I² = 79%). When the random effect model was used to merge MD values, the pooled MD was 0.58 (95% CI 0.26-0.90, Z = 3.53, P = 0.0004). This indicated that FVC was statistically significantly higher in the experimental group than in the control group ( Figure 3A).
The two studies (Sun, 2005;Chen et al., 2012) that compared TLC% pred included a total of 88 participants, 45 and 43 in experimental group and control group, respectively. The two studies had homogeneity (heterozygosity test, Chi² = 0.93, P = 0.33, I² = 0%). When the fixed effect model was used to merge MD values, the pooled MD was 5.90 (95% CI 1.56-10.24, Z = 2.66, P = 0.008). This indicated that TLC% pred was statistically significantly higher in experimental group than control group ( Figure 3C).
The four studies (Wei and Qiang, 2007;Zhao et al., 2016;Ma, 2018;Guo et al., 2019) that compared DLCO included a total of 370 participants, 194 and 176 in experimental group and control group, respectively. The four studies had heterozygosity (heterozygosity test, Chi² = 93.83, P < 0.00001, I² = 97%). When the random effect model was used to merge MD values, the pooled MD was 3.18 (95% CI 1.13-5.24, Z = 3.04, P = 0.002). This indicated that DLCO was statistically significantly higher in the experimental group than control group ( Figure 3D).
The three studies (Sun et al., 2008;Wu et al., 2012;Guo et al., 2019) that compared activity limitation score of SGRQ score included a total of 226 participants, 114 and 112 in experimental group and control group, respectively. The three studies had heterozygosity (heterozygosity test, Chi² = 13.94, P = 0.0009, I² = 86%). When the random effect model was used to merge MD values, the pooled MD was -5.26 [95% CI (-14.55)-(4.03), Z = 1.11, P = 0.27]. This indicated that there was no significant difference between experimental group and control group ( Figure 5C) The three studies (Sun et al., 2008;Wu et al., 2012;Guo et al., 2019) that compared impact score of SGRQ score included a total of 226 participants, 114 and 112 in experimental group and control group, respectively. The three studies had heterozygosity (heterozygosity test, Chi² = 159.37, P < 0.00001, I² = 99%). When the random effect model was used to merge MD values, the pooled MD was -13.11 [95% CI (-40.23)-(14.02), Z = 0.95, P = 0.34]. This indicated that there was no significant difference between experimental group and control group ( Figure 5D).
The two studies (Meng et al., 2016;Miao et al., 2018) that compared Borg scale questionnaire score included a total of 154 participants, 78 and 76 in experimental group and control group, respectively. The two studies had heterozygosity (heterozygosity test, Chi² = 6.10, P = 0.01, I² = 84%). When the random effect model was used to merge MD values, the pooled md was -0.96 [95% CI (-1.48)-(-0.43), Z = 3.56, P = 0.0004]. This indicated that Borg scale questionnaire score was statistically significantly lower in experimental group than control group ( Figure 5E).

Publication Bias Analysis
The publication bias was analyzed by funnel plots, which was drawn with the OR value of each outcome as the horizontal coordinate and SE (log [OR]) as the longitudinal coordinates. The funnel plots showed a basically inverted and symmetrical funnel shape. The results showed that there is no obvious publication bias. Funnel plots of total effective rate of clinical efficacy was shown in Figure 7.

DISCUSSION
IPF is a kind of interstitial lung disease characterized as chronic, progressive and fibrosis (Allen et al., 2020). IPF cannot be cured at present. The purpose of treatment is to delay disease progress, improve quality of life and prolong survival (Cerri et al., 2019). IPF has poor prognosis, median survival time after diagnosis is about 2 to 3 years. Pulmonary function (FVC, TLC, DLCO), PaO 2 , SGRQ score, 6MWD and cough, dyspnea symptoms are highly correlated with prognosis which are independent risk factors for IPF death (Lechtzin et al., 2013;Kim et al., 2015;Nathan et al., 2015). IPF has fewer drug options, clinical  [-38.72, -29.28] MD, -25.00 [-30.26, -19.74] MD, 1.00 [-3.25, 5.25] MD, -35.00 [-37.93, -32.07] MD, -14.82 [-15.78, -13.86 guidelines have made it clear that glucocorticoids and Nacetylcystine are not recommended or used as appropriate (Raghu et al., 2011;Group of Interstitial Lung Diseases, Respiratory Diseases Branch, Chinese Medical Association, 2016), while pirfenidone and nintedanib have certain curative effect in the treatment of IPF, but due to the high price and some side effects, they are restricted in patient use (Noble et al., 2011;Lee et al., 2013;Ryerson et al., 2019). In recent years, the position of TCM in the treatment of IPF is becoming more and more important, and the clinical research and meta-analysis have shown that the herbal medicine treating IPF could improve the clinical symptoms, delay the reduction of the lung function, improve the quality of life of the patients Chen et al., 2019;Wu et al., 2019).
DangGuiBuXue Decoction is composed of RA and RAS, which has the effect of replenishing qi and generating blood. It has a history of nearly 800 years. The prescription reuses RA to replenish the qi of spleen and lung to generate the source of blood, with RAS to benefit blood and camp. Experiment studies have shown that DangGuiBuXue Decoction has a good therapeutic effect on hepatic fibrosis in rabbits (Wang and Liang, 2010), has antifibrotic effects on adriamycin-induced nephropathy in rats (Wei et al., 2012) and has antifibrosis effects on bleomycin-induced pulmonary fibrosis in rats (Gao et al., 2011;Gao et al., 2012;Zhao et al., 2015).
At present, the prescription of TCM in the treatment of IPF based on the association rules of the literature shows that the treatment of IPF with TCM is mainly related to benefiting vital energy and promoting blood circulation, among which RA and RAS are the most common herbs for invigorating qi and activating blood (Ren, 2017;Huang et al., 2018). There are many experiments on the treatment of IPF, which manifest RA and RAS can improve pulmonary fibrosis in animal model (Liu, 2009;. Our recent research shows that RA and RAS should play an effective role in the treatment of IPF through multiple targets and multiple pathways . Currently, the main study end point of IPF is the absolute value of FVC, and the secondary study end point is quality of life score and 6MWD (Noble et al., 2011;Lee et al., 2013;Ryerson et al., 2019). We analyzed these indicators primarily. In this study, the RCTs of RA and RAS in the treatment of IPF were systematically evaluated and meta-analysis was carried out. The results of meta-analysis show that total effective rate and TCM syndrome effective rate were statistically significantly higher in experimental group than control group, which suggest that RA and RAS can significantly improve the curative effect of IPF; FVC, FVC% pred, TCL% pred, DLCO and DLCO% pred, were statistically significantly higher in experimental group than control group, which suggest that RA and RAS is beneficial to pulmonary function of patients with IPF; 6MWD was statistically significantly higher in experimental group than control group and Borg scale questionnaire score was statistically significantly lower in experimental group than control group, which suggest that RA and RAS can improve exercise tolerance in patients with IPF; there was no significant difference between experimental group and control group compared total SGRQ scores, activity limitation scores and impact scores, but symptoms scores of SGRQ scores was statistically significantly lower in experimental group than control group, which suggest that RA and RAS can improve respiratory symptoms in patients with IPF, and other indexes may have more influencing factors.
We have also conducted a meta-analysis of other indicators. PaO 2 were statistically significantly higher in experimental group than control group, which suggest that RA and RAS can improve the oxygenation in patients with IPF and there was no significant difference between experimental group than control group compared SaO 2 , which may be related to the characteristics of the oxygen dissociation curve ( Figure S3). TNF-a was statistically significantly lower in experimental group than control group and there was no significant difference between experimental group than control group compared TGF-b1, which suggest that inhibitory inflammatory factors may play a role of RA and RAS in the treatment of IPF, but more samples are needed to further verify it ( Figure S4).
In this systematic evaluation, the TCM syndrome effective rate and syndrome score of TCM were analyzed and made metaanalysis. The results of meta-analysis showed that TCM syndrome effective rate of clinical effect was statistically significantly higher in experimental group than control group; cough, wheezing, short of breath, fatigue, thirst, coated tongue and pulse manifestation syndrome score of TCM were statistically significantly lower in experimental group than control group. These results suggest that RA and RAS is effective in treating IPF, especially could improve the syndrome of cough, wheezing, short of breath and other syndrome which are closely related to the respiratory system ( Figure S5).
It has been reported that TCM has potential hepatotoxicity (Teo et al., 2016;Pan et al., 2020). We also analyzed adverse reactions of include studies. Incidence of adverse reactions was statistically significantly lower in experimental group than control group, which suggest that the clinical application of RA and RAS in the treatment of IPF is safe. And there was no significant potential hepatotoxicity of RA and RAS in the treatment of IPF. Interestingly, elevated aminotransferase A B C D E FIGURE 3 | Forest plot of comparison: pulmonary function tests. (A) FVC was statistically significantly higher in experimental group than control group. (B) FVC% pred was statistically significantly higher in experimental group than control group. (C) TLC% pred was statistically significantly higher in experimental group than control group. (D) DLCO was statistically significantly higher in experimental group than control group. (E) DLCO% pred was statistically significantly higher in experimental group than control group. occurred in the control group. It is speculated that the dialectical use of TCM may reduce the toxicity and side effects of western drugs such as prednisone.
However, there are some limitations in this systematic evaluation. First of all, the study of only using RA and RAS in the treatment group is less, and we included the studies using RA and RAS as the main component in experimental group. The role of other traditional herbal medicine will have a certain impact on the results, but the role of RA and RAS as the main component is still of great significance. The next step of our research is to carry out a comparative RCT of long-term treatment of RA and RAS only in IPF. In view of the clinical particularity of TCM, and in accordance with the characteristics of real world situation, we believe that in our future read world clinical research, the experimental group should also be allowed to take other drugs, including other herbal medicine, on the basis of adhering to the rules of using RA and RAS. Secondly, some of the random methods are not clear; most of the studies do not introduce Comparing total score of SGRQ score, there was no significant difference between experimental group and control group. (B) Symptoms score of SGRQ score was statistically significantly lower in experimental group than control group. (C) Comparing activity limitation score of SGRQ score, there was no significant difference between experimental group and control group. (D) Comparing impact score of SGRQ score, there was no significant difference between experimental group and control group. (E) Borg scale questionnaire score was statistically significantly lower in experimental group and control group. allocation concealment; most of the studies do not introduce blindness; two studies had inaccurate outcome data; and all studies were unable to know if there were selective reports. Although the quality of some research methods is low, we carefully evaluate the literature to ensure that the results are true and credible. Lastly, the treatment methods were not uniform, the dosage of RA and RAS was not the same, and the drugs in the control group were also different. Some of the research treatment cycles were short, and the safety of long-term combination of RA and RAS in the treatment of IPF could not be accurately evaluated. The existence of these biases may affect the accuracy of the research conclusions. However, our research is mainly to study the use of RA and RAS in IPF patients, so there is no special regulation on the dose and the included studies were RCTs and the diagnostic criteria was consistent, the baselines for inclusion in the literature do not differ significantly. All the prescriptions in included studies were prepared according to Chinese pharmacopeia by experts and famous old Chinese medicine practitioners and there have been many high performance liquid chromatography (HPLC) studies on RA and RAS in the past (Liu et al., 2006;Yao et al., 2019).

CONCLUSIONS
To sum up, RA and RAS are effective and safe in the treatment of IPF, which is beneficial to pulmonary function and exercise tolerance of these patients. Because the quality of the study is low, the quantity and sample size are small, and more high quality, multi-center, large sample RTCs are needed to obtain better evidence.

AUTHOR CONTRIBUTIONS
YZ conducted the database search, assessed studies for inclusion, extracted and analyzed the data, and drafted the manuscript.
LG drafted the manuscript, amended English writing of this review, and revised the manuscript. QX assessed studies for inclusion, extracted the data, and arbitrated any disagreements. LT amended English writing of this review and arbitrated any disagreements. JQ conducted the database search, assessed studies for inclusion, extracted and analyzed the data, and drafted the manuscript. MC supervised YZ, LG, and JQ to perform this review and revised the manuscript.

SUPPLEMENTARY MATERIAL
The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fphar.2020. 00415/full#supplementary-material FIGURE 6 | Forest plot of comparison: adverse reactions. Incidence of adverse reactions was statistically significantly lower in experimental group than control group.
FIGURE 7 | Funnel plots of total effective rate of clinical efficacy. The funnel plots showed a basically inverted and symmetrical funnel shape. The results showed that there is no obvious publication bias.