Malaria Control During Mass Population Movements and Natural Disasters (2003)
Chapter: Appendix C: Alternative Treatment Regimens for Severe Malaria
APPENDIX C
Alternative Treatment Regimens for Severe Malaria
The recommended treatment regimen for management of severe malaria given in Chapter 6 assumes that a fairly high level of patient care is possible (i.e., availability of intravenous therapy). There are clearly situations where this would not be the case. The following regimens allow for treatment of severe malaria in settings where such capacity is not available (World Health Organization, 2000a, 2000b).
Note: The use of suppositories containing an artemisinin drug is based on limited clinical experience but is the subject of ongoing clinical trials.
INTRAMUSCULAR QUININE
Loading Dose
Quinine dihydrochloride is given intramuscularly at 20 mg salt/kg diluted to 60 mg/ml in normal saline. The dose should be split between two injection sites in the anterior thigh (not the buttocks).
Maintenance Dose
Eight hours after the loading dose, quinine dihydrochloride is given intramuscularly at 10 mg salt/kg and repeated every 8 hours until the patient can take oral medication. Oral medication should follow the regimen described in Chapter 6.
INTRAMUSCULAR ARTEMISININ DRUGS
Artesunate can be given intramuscularly at 2.4 mg/kg initially, followed by 1.2 mg/kg 12 hours and 24 hours later, then 1.2 mg/kg daily for 6 days. An oral artemisinin compound can be used once the patient can take oral medication. Alternatively, after a minimum of 3 days of artesunate, patients able to take oral medications can be switched to another antimalarial drug appropriate to the area (e.g., either sulfadoxine/pyrimethamine or mefloquine in areas where those drugs remain effective).
Artemether can be given intramuscularly at 3.2 mg/kg on the first day, followed by 1.6 mg/kg daily for 6 days. An oral artemisinin compound can be used once the patient can take oral medication. Alternatively, after a minimum of 3 days of artesunate, patients able to take oral medications can be switched to another antimalarial drug appropriate to the area (e.g., either sulfadoxine/pyrimethamine or mefloquine in areas where those drugs remain effective).
INTRARECTAL ARTEMISININ DRUGS
Artemisinin suppositories can be given using a 40 mg/kg loading dose, followed by 20 mg/kg at 4, 24, 48, and 72 hours. Patients able to take oral medications can then be switched to an oral artemisinin drug at an appropriate dose or another antimalarial drug appropriate to the area (e.g., either sulfadoxine/pyrimethamine or mefloquine in areas where those drugs remain effective).
Artesunate suppositories can be given using one 200-mg suppository initially, followed by one 200-mg suppository at 12, 24, 36, 48, and 60 hours. Patients able to take oral medications can then be switched to an oral artemisinin drug at an appropriate dose or another antimalarial drug appropriate to the area (e.g., either sulfadoxine/pyrimethamine or mefloquine in areas where those drugs remain effective).
For additional details and recommendations, refer to World Health Organization (2000a, 2000b).
