By Dr Ananya Mandal, MD
Malaria can be a potentially fatal disease especially when caused by Plasmodium falciparum. Treatment should be initiated as soon as possible after diagnosis is made. Treatment can be both by oral drugs as well as intravenous injections of antimalarials. Most drugs used in treatment are active against the parasite forms in the blood.
Choice of treatment
Treatment of a malaria patient depends on several factors including;
Species of Plasmodium affecting the individual.
Clinical condition of the patient. A very ill patient or one with severe complications may need a different regimen of anti-malarials compared to one with a milder disease.
Area of acquisition of malaria. This is important because Plasmodium parasites in certain high-risk malaria areas are resistant to common anti-malarial drugs and drug regimens for these individuals need to be chosen with care.
Associated diseases and illnesses.
Pregnant mothers with malaria - aAll drugs may not be prescribed in a pregnant mother for fear of harm to the unborn baby
Presence of a history of drug allergies or other medications used by the patient.
Treatment promptly with antimalarial agents can usually result in a full recovery. Drugs that are used to prevent malaria in travellers are also useful in treatment of malaria. Sometimes a combination of different antimalarials may be prescribed to overcome strains of malaria that have become resistant to single types of medication.
Antimalarial medication is usually given as tablets or capsules. Hospital admission is needed for severely ill patients, patients with Plasmodium falciparum malaria, mixed infections and unidentified strains of malaria. There are several types of antimalarials used to prevent and treat malaria.
Drugs used in treatment of malaria include:-
Artemether-lumefantrine (Riamet® or Coartem ®)
Mefloquine (Lariam ®)
Doxycycline (used in combination with quinine)
clindamycin (used in combination with quinine)
Artesunate (not licensed for use in the United States and European Union)
Recommendations for patients with Non-falciparum malaria
These patients are usually not admitted to the hospital for treatment and can be treated in the out-patient department unless there are complications. Chloroquine as the drug of choice for the treatment of all non-falciparum malaria. It is highly effective against P. malariae and Plasmodium ovale and most strains of Plasmodium vivax.
There are areas with strains resistant to choloriquine. Malaria from and in these areas can be managed by other agents like quinine, artemether with lumefantrine or atovaquone-proguanil.
Before prevention of relapse primaquine is used. It destroys the liver stage parasites. For treatment of P. ovale 15 mg primaquine/day for 14 days and for some strains of P. vivax higher doses of primaquine - 30 mg primaquine/day for 14 days may be used. G6PD activity should be measured in Plasmodium vivax or Plasmodium ovale infections as the primaquine can cause haemolysis (break down of RBCs) in those with G6PD deficiency.
Recommendations for patients with falciparum malaria
As per recommendations, all patients with falciparum malaria should be admitted to hospital initially. These patients need supportive management in the HDU (highly dependent unit) or ICU in presence of complications.
Treatment is usually with oral quinine sulphate 600 mg every 8 hours for 5-7 days plus doxycycline 200 mg daily (or clindamycin 450 mg every eight hours for pregnant women) for 7 days.
Another alternative is Atovaquone-proguanil 4 standard tablets daily for 3 days. Treatment is also effective with Artemether with lumefantrine (Riamet®). The dose for patients over 35 kg is 4 tablets at once and then a further 4 tablets at 8, 24, 36, 48 and 60 hours.
Recommendations for patients with severe or complicated falciparum malaria
These patients require intravenous drugs. Intravenous quinine dihydrochloride is usually the first line agent. Initial dose is 20 mg/kg (to a maximum of 1.4 g) over 4 hours, followed by 10 mg/kg (to a maximum of 700 mg) every 8 hours for the first 48 hours or until the patient can swallow. Once the patient can take oral drugs quinine sulphate 600 mg thrice a day is given to complete a 5-7-day course in total.
The artesunate regimen is usually given as an IV injection, repeated at 12 and 24 hours and daily thereafter. Intravenous artesunate has not been licensed in the European Union but there is accumulating evidence that it offers a significant benefit over quinine where patients have very severe malaria or high parasite counts.
Alternatively a second drug can be given with these regimes. These include doxycycline 200 mg once daily or clindamycin 450 mg thrice daily (for pregnant women) for a total of 7 days from when the patient can swallow.
Reviewed by April Cashin-Garbutt, BA Hons (Cantab)