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Table 2 Recommended regimens for initial parenteral treatment of severe falciparum malaria

From: Clinical review: Severe malaria

Drug

Loading dose1

Maintenance dose

Comments

Regimen 1

   

Quinine dihydrochloride salt (available outside the USA), reconstituted in 5% glucose or normal saline

7 mg salt/kg iv over 30 min followed immediately by maintenance dose OR20 mg salt/kg over 4 hours, followed 8 hours later by maintenance dose

10 mg salt/kg diluted in10 ml/kg isotonic fluid iv over4 hours repeated every 8 hours2

If hemodialysis is performed, then quinine is administered after dialysis. Monitor blood glucose because of risk for developing hyperinsulinemic hypoglycemia

PLUS (either concurrently or immediately thereafter)

Doxycycline3

Not required

1.5 mg/kg (usually 100 mg) po or iv every 12 hours for 7 days

Should not be given to pregnant or breast-feeding women or children < 8 years old

Regimen 2

   

Quinidine gluconate(available in the USA), reconstituted in normal saline

10 mg salt/kg (equivalent to6.2 mg base/kg) iv infused over 1–2 hours, followed immediately by maintenance dose

0.02 mg/kg/min salt (equivalent to 0.0125 mg/kg/min base) continuous iv infusion2

Electrocardiographic monitoring is mandatory; slow or stop infusion if QRS lengthens >25% of baseline value or QTc interval > 500 ms

PLUS (either concurrently or immediately thereafter)

   

Doxycycline3

Not required

Same as above

 

Regimen 3

   

Artesunate

2.4 mg/kg iv bolus

1.2 mg/kg iv daily4

Artesunic acid 60 mg is dissolved in 0.6 ml 5% sodium bicarbonate, diluted to 3–5 ml 5% glucose, and given immediately by iv bolus injection

PLUS

   

Mefloquine

15 mg/kg (750 mg) base

10 mg/kg (500 mg) base po at 6–8 hours and (if >60 kg) followed by 5 mg/kg (250 mg) po at 16 hours

Total dose: 1500 mg

Regimen 4

   

Artemether

3.2 mg/kg im

1.6 mg/kg im daily4

 

PLUS

   

Mefloquine

Same as above

Same as above

 
  1. 1Loading dose should not be administered to patients who received quinine, quinidine, halofantrine, or mefloquine within the preceding 12 hours. 2Intravenous quinine or quinidine should be given for at least 24 hours but oral antimalarial treatment should be substituted as soon as the patient is stable and can take oral therapy to complete the treatment course. If intravenous treatment is continued past 48 hours, then the maintenance dose should be reduced by 30–50%. In renal failure and in dialysis patients, the maintenance dose of quinine should be reduced by 30–50%. 3Clindamycin 5 mg/kg (usually 300 mg) po or iv every 8 hours can be administered if the patient is unable to take doxycycline. 4Parenteral artesunate or artemether should be given for at least 3 days but oral antimalarial treatment should be substituted as soon as the patient is stable and can take oral therapy to complete the treatment course. im = intramuscularly; iv = intravenously; po, orally.