Patient seriously ill or unable to take tablets

IV artesunate is treatment of choice, but if not immediately available start with IV quinine. There is no added benefit from giving both agents.

Artesunate regimen: 2.4 mg/kg given as an intravenous injection at 0, 12 and 24h, then daily thereafter. After completion of a minimum of 24h therapy (maximum five days), a full course of an oral ACT should be taken when the patient can tolerate oral medication.

All patients receiving artesunate or ACT in hospital should have follow up full blood count 2 weeks later for possible anaemia.

OR

IV quinine: loading dose of 20 mg/kg quinine dihydrochloride in 5% dextrose or dextrose saline over 4h (usual maximum dose 1.4g), followed by 10 mg/kg (usual maximum 700 mg) every 8h for first 48h (or until patient can swallow). Frequency of dosing should be reduced to 12 hourly if intravenous quinine continues for more than 48 hours. Omit high loading dose if quinine, quinidine or mefloquine given within the previous 12h.

Parenteral quinine therapy should be continued until the patient can take oral therapy, when quinine sulphate 600 mg should be given three times a day to complete five to seven days of quinine in total.

Quinine treatment should always be accompanied by a second drug: doxycycline 200 mg (or clindamycin 450 mg three times a day for children or pregnant women), given orally for total of seven days from when the patient can swallow.

Patient not seriously ill and able to swallow tablets

Artemether with lumefantrine (Riamet): if weight is over 35kg, give four tablets initially, followed by five further doses of four tablets at 8, 24, 36, 48 and 60h (total 24 tablets over 60h).

or

Dihydroartemisinin-piperaquine (DHA-PPQ) is another co-artem combination that may be used: if 36–60kg, 3 tablets daily for 3 days; if >60kg 4 tablets daily for 3 days. See product literature cautions, especially in patients with cardiac conditions and/or taking agents that prolong QT interval.

or

Atovaquone with proguanil (Malarone) four tablets once daily for three days.

or

Quinine 600 mg of quinine salt 8-hourly PO for 5–7 days, PLUS doxycycline 200 mg daily PO (or clindamycin 450 mg 8-hourly) for 7 days (start these as soon as possible with the quinine).

It is not necessary to give doxycycline or clindamycin with or after treatment with agents other than quinine.