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.