Treatment of Malaria In India - Update part 2

Treatment of Severe Plasmodium Falciparum Malaria 

Should not be treated on out patient basis, as it requires parenteral administration of antimalarials and has a risk of mortality. 

1. Artesunate: It is the drug of choice. It should be given in a dose of 2.4 mg/kg IV on admission (0 hour), then at 12 hours and 24 hours and then once daily till the patient takes orally or for 7 days. Then, they should get full course of ACT for 3 days (Table 1). However, ACT containing MQ should be avoided in cerebral malaria due to possibility of development of neuropsychiatric complication

2. Quinine: It is an acceptable alternative to AS. It should be given at a dose of 20 mg quinine salt/kg of body weight in 5% dextrose/dextrose saline, over 4 hours, on admission. It is followed by 10 mg/kg of body weight 8 hourly infusions which should be started 8 hours after the 1st loading dose. The infusion rate should not exceed 5 mg/kg of body weight/hour. Initial loading dose should not be given if patient has already taken quinine. If quinine therapy is used beyond 48 hours, the dose should be reduced to 7 mg/kg of body weight 8 hourly till patient takes orally. Then, he should be given oral quinine in a dose of 10 mg/kg of body weight 8 hourly to complete 7 days of therapy. Quinine injection must not be given as bolus injection. It is always given in IV infusion. Doxycycline in a dose of 3 mg/kg of body weight per day for 7 days is to be added when the patient starts taking orally. Doxycycline is contraindicated in pregnancy and children below 8 years of age. In those cases, instead of doxycycline, clindamycin is to be given in a dose of 10 mg/kg of body weight 12 hourly for 7 days

3. Artemether: It should be given in the dose of 3.2 mg/kg of body weight intramuscularly on admission and 1.6 mg/kg of body weight intramuscularly once per day for 4 more days. Then, ACT is to be given for 3 days

4. Alpha-beta artemether: It should be given in a dose of 150 mg/day for 3 days intramuscularly. It is not recommended for children. It should be followed by ACT for 3 days. 

References

1. Guidelines for the Treatment of Malaria 2010 (2nd edition). World Health Organization, 20, Avenue Appia-CH-1211 Geneva 27.

2. Guidelines for Diagnosis and Treatment of Malaria in India 2011 (2nd edition). Government of India, National Institute of Malaria Research, New Delhi.

Treatment of Malaria In India - Update part 1

I had posted treatment guidelines for malaria in 2014, as per the existing guidelines. 

Newer guidelines have been introduced since. Hence, this update. 

1. Treatment of Uncomplicated Plasmodium Falciparum Malaria 

Artemisinin combination therapy (ACT) is the drug of choice for all confirmed cases of uncomplicated PF cases. This should be combined with primaquine (PQ) (0.75 mg/kg body weight or 45 mg) on day-2. The ACT recommended in the National Program in India is artesunate (AS) + sulfadoxine and pyrimethamine (SP). Oral AS monotherapy is banned in India.

2. Treatment of Uncomplicated Plasmodium Vivax malaria

Chloroquine is the drug of choice of Plasmodium vivax (PV) cases. It is given at a dose of 10 mg/kg (600 mg) on day-1 and day-2 and 300 mg on day-3. Primaquine at a dose of 0.25 mg/kg (15 mg/day) for 14 days is tobe added to prevent relapse. Primaquine is contraindicated in G6PD deficiency cases, infants and pregnant women.

Post CoViD complex

Post CoViD complex is a cluster of conditions which may effect a person convalescing from active CoViD infection, 4 or more weeks after the initial infection. The initial may or may not be clinically detectable. As this is an evolving disease and not much definitive research has been done, we are still finding newer and varied conditions, causation of which  is not otherwise explainable. 

According to the information on the CDC USA website, there can be 2 types of symptoms

1. New symptoms

2. Ongoing symptoms

New Symptoms - These are the symptoms which were not present during the initial infection period and have arisen 4 weeks after that. 

Ongoing Symptoms - These are the symptoms which started during the initial infection and never completely went away after the initial infection. 

Following is a list of common symptoms 

1. Difficulty breathing or shortness of breath
2. Tiredness or fatigue
3. Symptoms that get worse after physical or mental activities (also known as post-exertional malaise)
4. Difficulty thinking or concentrating (sometimes referred to as “brain fog”)
5. Cough
6. Chest or stomach pain
7. Headache
8. Fast-beating or pounding heart (also known as heart palpitations)
9. Joint or muscle pain
10. Pins-and-needles feeling
11. Diarrhea
12. Sleep problems
13. Fever
14. Dizziness on standing (lightheadedness)
15. Rash
16. Mood changes
17. Change in smell or taste
18. Changes in menstrual period cycles

Prevention

The best way to prevent post-CoViD conditions is to prevent COVID-19 illness.

Source - National Center for Immunization and Respiratory Diseases (NCIRD), Division of Viral Diseases