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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.