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All
cases of P. vivax malaria and uncomplicated cases of P.
falciparum malaria are treated with oral drugs. Chloroquine is the
ONLY drug used for P. vivax malaria, because resistance to
chloroquine in P. vivax malaria is almost unknown (only
sporadic reports). In areas where P. falciparum is sensitive to
chloroquine, it can be treated with chloroquine; however, in areas with
known resistance to chloroquine, artemisinin combination therapies are
now recommended. Primaquine should be used in P. vivax and P.
ovale malaria for eradicating the persisting liver forms and in
P. falciparum malaria to destroy the ganmetocytes so as to prevent
the spread of infection.
Go to Treatment
of P. vivax / P. ovale / P. malariae |
Treatment of Uncomplicated
P. falciparum |
Treatment of Severe Malaria
Dose
of commonly used antimalarial drugs
|
Age in years |
Dose of Chloroquine (as base)
(Each 250 mg tablet contains 150 mg base and
each 5 ml of suspension contains 50 mg base) |
Dose of Primaquine |
Dose of Pyri/Sulpha
(Of 25+500 mg tablet) |
| 1st dose* |
2nd dose |
3rd dose |
4th dose |
P.vivax/ P.ovale/ mixed
(for 14 days) |
P. falciparum Single dose |
|
0-1 |
75 mg |
37.5 mg |
37.5 mg |
37.5 mg |
Nil |
Nil |
1/4 tablet |
|
1-5 |
150 mg |
75 mg |
75 mg |
75 mg |
2.5 mg |
7.5 mg |
1/2 tablet |
|
5-9 |
300 mg |
150 mg |
150 mg |
150 mg |
5 mg |
15 mg |
1 tablet |
|
9-14 |
450 mg |
225 mg |
225 mg |
225 mg |
10 mg |
30 mg |
2 tablets |
|
>14 |
600 mg |
300 mg |
300 mg |
300 mg |
15 mg |
45 mg |
3 tablets |
*1st
dose of chloroquine should always be larger to obtain sufficient blood
levels, in view of large volume of distribution.
Dose spacing for
chloroquine |
1st dose |
2nd dose |
3rd dose |
4th dose |
If the patient comes in the morning and treatment
can be started by mid-day |
Stat. |
After 6 hours |
After 24 hours |
After 48 hours |
If the patient comes in the afternoon and treatment
is started by evening |
Stat |
After 12 hours |
After 24 hours |
After 36 hours |
If the patient is coming from a far off place and
/or if the MP test report is available only next day |
Stat (as presumptive) |
2nd and 3rd
doses together after 24 hours |
After 48 hours |
Parenteral Chloroquine:
Parenteral chloroquine may be needed in patients with drug sensitive
malaria with persistent vomiting. It should never be used as a bolus
injection.
Intravenous infusion |
10 mg / kg (max.600mg) in isotonic fluid, over 8
hours; followed by 15 mg / kg (max.900mg) over 24 hours. |
Intramuscular or subcutaneous injections |
3.5 mg of base/ kg (max.200 mg) every 6 hours or
2.5 mg of base/ kg (max.150mg) every 4 hours.
(Intramuscular injection can cause fatal hypotension, especially in children) |
Treatment
of complicated/ chloroquine resistant P. falciparum malaria
All
cases of severe P.
falciparum malaria as chloroquine resistant, unless one is very certain about the
sensitivity. It is better to use two drugs, one rapid acting and one slower acting. Severe
malaria should always be treated with parenteral antimalarials to ensure adequate
treatment.
See
Treatment of severe malaria
Quinine
Intravenous |
In
intensive care unit: 7mg of salt/kg over 30 minutes, followed immediately by 10mg/kg
diluted in 10ml/kg isotonic fluid over 4 hours; after 4 hour interval, 10mg/kg over 4
hours, repeated every 8-12 hours until patient can swallow.
OR
20mg of salt/kg
diluted in 10 ml/kg isotonic fluid, infused over 4 hrs; then 10 mg of salt / kg over 4
hrs, every 8-12 hrs until patient can swallow.
Children: 24 mg of salt/kg diluted in 10 ml/kg isotonic fluid, infused over 4 hrs;
then 12mg of salt/kg over 4 hrs, every 8-12 hrs until patient can swallow. |
Intramuscular |
20mg of salt/kg diluted to 60 mg/ml by deep i.m. injection, (divided into two sites); then
10mg of salt/kg every 8 hours. |
Oral |
Adults:
600mg of salt 3 times a day for 7 days (max. of 1800mg/day) Children: Approximately 10mg/kg 3 times a day for 7 days. |
In areas where resistance to quinine is known or
suspected, add single dose of pyrimethamine/ sulphadoxine OR Tetracycline or Doxycycline
for 7 days (for non-pregnant adults only) |
Artemisinin
derivatives
Preparation |
Dose and administration |
Artemether:
(Availability: 80 mg/ml Inj. and 40 mg cap.) |
IM: 3.2mg/kg as loading dose, followed by 1.6mg/kg daily, until patient is able to swallow or
for 5 days. (Maximum dose: 480 mg in adults and 9.6mg/kg in children.)
Oral: 160mg in two doses on the first day, then 80 mg/day for total 5 days |
Arteether:
(Availability: 150mg/2 ml injection) |
Adults:
150mg IM once daily for 3 consecutive days. Children: 3 mg/kg once daily for 3
consecutive days. |
Artesunate:
(Availability: 60mg powder with 1 ml of 5% sodium bicarbonate ampoule for injection and
50 mg tablet) |
Injection:
The powder should be reconstituted in 1 ml of 5% sodium bicarbonate and then further
diluted with isotonic saline or 5% dextrose (to a total of 3 ml for im and 6 ml for iv
use).
Dose: 2.4mg/kg on the first day (additional 1.2 mg/kg after 4 hours in case of
severe falciparum malaria), followed by 1.2 mg/kg daily until patient is able to swallow
or for a maximum of 7 days.
Oral: 100 mg on the first day, followed by 50 mg/ day
for 7 days. |
Other drugs
Drug |
Dose |
Mefloquine |
15-25
mg/kg (max. of 1500 mg), given as two doses, 6-8 hrs apart |
Tetracycline |
250
mg 4 times a day for 7 days (for patients > 8 years and non-pregnant) |
Doxycycline |
100
mg twice a day for 7 days (for patients > 8 years and non-pregnant) |
|
See: Combinations of Antimalarial Drugs |
Important
-
Most blood schizonticidal drugs prevent
the development of the forthcoming erythrocytic cycle of parasitic development and hence
have no or little effect on the ongoing cycle that is already causing fever. Therefore, it
would take at least 48 hours for the treatment to be effective.
-
In severe P. falciparum malaria,
oral antimalarials should not be used. Vomiting, poor general health, poor compliance,
erratic G.I. absorption due to splanchnic vasculopathy etc. make oral therapy less
reliable. Therefore, use only parenteral antimalarials. This also means that oral only
antimalarials like Mefloquine and Halofantrine have no place in treating severe falciparum
malaria.
-
In all cases of P. falciparum
malaria, the antimalarial drugs should be chosen depending on the severity of the illness
and the sensitivity pattern in the locality. Changing the drugs or adding the drugs in
between is not advisable.
-
Most antimalarial drugs have a long plasma
half-life. Therefore, adding similar drugs half way through the treatment will only add to
the adverse effects and not to the therapeutic benefit. The following combinations should
therefore be avoided, concurrently or within a short interval:
(1.) Chloroquine + Quinine (2.) Chloroquine + Mefloquine (3.) Quinine + Mefloquine (5.)
Quinine + Primaquine (6.) Quinine + Halofantrine (7.) Mefloquine + Primaquine (8.)
Administration of Primaquine and Pyrimethamine/sulphadoxine on the same day is also not
advisable. Both sulpha and primaquine can precipitate hemolytic crisis in patients with Glucose 6-phosphate dehydrogenase deficiency.
-
Do not exceed the maximum recommended dose
of antimalarial drugs. All antimalarial drugs have a narrow safety range and excess dose
may lead to adverse effects. Moreover, larger dose does not offer any superior
antimalarial effect.
-
Primaquine should
be administered to ALL cases of malaria as radical treatment except in the following
situations where it is contraindicated: (i.) Pregnancy and lactation (ii.) Infants below
one year of age. In these two categories, chloroquine should be given every week as a
suppressive chemoprophylaxis to prevent relapse of vivax malaria. When these patients are
fit for administration of primaquine, they should be given full therapeutic dose of
chloroquine as well as primaquine. (iii.) Patients with known Glucose 6-phosphate
dehydrogenase deficiency (iv.) Concurrently with quinine, mefloquine and halofantrine (v.)
It should not be used on the same day with sulphadoxine. In such cases it can be given the
next day.
-
Do not misuse the
newer antimalarial drugs. We need to preserve them for future. Research into newer
antimalarial drugs is scanty and the parasite is fast developing resistance even for newer
drugs. Thus if we deplete the newer drugs by misusing them, we may not have anything left
for treating ALL DRUG RESISTANT malaria in the not-too-far-future. Therefore, newer anti
malarial drugs should be used only when definitely indicated and not indiscriminately.
These drugs should be used ONLY when parasite index or other methods PROVE drug resistant
malaria. In addition, artemisinin derivatives can be used in cases of hyperparasitemia or
life-threatening complications on account of their ability to clear the parasitemia
earlier compared to other anti malarial drugs.
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