Artemether-lumefantrine (coartem) | P. falciparum from chloroquine resistant or unknown areas | Tablet: 20 mg artemether, limefantrine. Dose: 4 tablets Day 1: 2 doses separated by 8 hours; thereafter bid × 2d | Wt. (kg) 5-15 15-25 25-<35 >35 Use same 3-day schedule as adluts | Tablets (per dose) 1 2 3 4 | Adults; headache anorexia, dizziness, asthenia, arthralgia myalgia Children: fever, cough, vomiting, loss of appetite, headache | Take with food or whole milk. If patient vomits within 30 minutes, repeat dose. Contraindicated in pregnancy |
Artesunate (IV; available from U.S. Center for Disease Control and Prevention) | Severe malaria (see CDC guidelines) | U.S. treatment IND (CDC): 4 equal doses of artesunate (2.4 mg/kg each) over a 3-day period followed by oral treatment with atovaquone-proguanil, doxycycline, clindamycin, or mefloquine (to avoid emergence of resistance) | | See Artemether | See Artemether and CDC guidelines |
Atovaquone-proguanil malarone (oral) | Plasmodium falciparum from chloroquine-resistant areas; can be used for P. vivax | Adult tablet 250 mg atovaquone/100 mg, proguanil 4 Adult tablets orally per day × 3 d | Pediatric tablet = 62.5 mg atovaquone/25 mg proguanil 5-8 kg: 2 ped tab orally per day × 3 d >8-10 kg: 3 ped tab orally daily × 3 d >10-20 kg: 1 adult tab orally daily × 3 d >20-30 kg: 2 adult tab orally daily × 3 d >30-40 kg: 3 adult tab orally daily × 3 d >40 kg: 4 adult tab orally daily × 3 d | Abdominal pain, nausea, vomiting, diarrhea, headache, rash, mild reversible elevations in liver aminotransferase levels | Not indicated for use in pregnant women due to limited data Contraindicated if hypersen to atovaquone or proguanil; severe renal impairment (creatinine clearance <30 mL/min) Should be taken with food to increase absorption of atovaquone |
Chloroquine phosphate | P. falciparum from chloroquine sensitive areas P vivax from chloroquine sensitive areas All P. ovale All P malariae All P. knowlesi | 600 mg base (1000 mg salt) orally immediately, followed by 300 mg base (500 mg salt) orally at 6, 24, and 48 h Total dose: 1500 mg base (2500 mg salt) | 10 mg base/kg orally immediately, followed by 5 mg base/kg orally at 6, 24, and 48 h Total dose: 25 mg base/kg | Nausea, vomiting, rash, headache, dizziness, urticaria, abdominal pain, pruritus | Safe in children and pregnant women Give for chemoprophylaxis (500 mg salt orally every week) in pregnant women with chloroquine-sensitive P. vivax Contraindicated if retinal or visual field change; hypersensitivity to 4-aminoquinolines Use with caution in those with impaired liver function since the drug is concentrated in the liver |
Clindamycin (oral or IV) | P. falciparum from chloroquine-resistant areas P vivax from chloroquine-resistant areas | Oral: 20 mg base/kg/d orally divided 3 times daily × 7 d IV: 10 mg base/kg loading dose IV followed by 5 mg base/kg IV every 8 h; switch to oral clindamycin (as above) as soon as patient can take oral meds; duration = 7 d | Oral: 20 mg base/kg/d orally divided 3 times daily × 7 d IV: 10 mg base/kg loading dose IV followed by 5 mg base/kg IV every 8 h; switch to oral clindamycin (oral dose as above) as soon as patient can take oral medication; treatment course = 7 d | Diarrhea, nausea, rash | Always use in combination with quinine-quinidine Safe in children and pregnant women |
Doxycycline (oral or IV) | P falciparum from chloroquine-resistant areas P vivax from chloroquine-resistant areas | Oral: 100 mg orally twice daily × 7 d IV: 100 mg IV every 12 h and then switch to oral doxycycline (as above) as soon as patient can take oral medication; treatment course = 7 d | Oral: 2.2 mg/kg orally every12 h × 7 d IV: IV only if patient is not able to take oral medication; for children <45 kg, give 2.2 mg/kg IV every 12 h and then switch to oral doxycycline (dose as above) as soon as patient can take oral medication; for children >45 kg, use same dosing as for adults; duration = 7 d | Nausea, vomiting, diarrhea, abdominal pain, dizziness, photosensitivity, headache, esophagitis, odynophagia Rarely hepatotoxicity, pancreatitis, and benign intracranial hypertension seen with tetracycline class of drugs | Always use in combination with quinine or quinidine Contraindicated in children < 8 y, pregnant women, and persons with known hypersensitivity to tetracyclines Food and milk decrease absorption of doxycycline, will decrease GI disturbances To prevent esophagitis, take tetracyclines with large amounts of fluids, (patients should not lie down for 1 h after taking the drugs) Barbiturates, carbamazepine, or phenytoin may cause reduction in Cp of doxycycline |
Hydroxychloro-quine (oral) | Second-line alternative for treatment of: P. falciparum and P. vivax from chloroquinesensitive areas All P. ovale All P. malariae | 620-mg base (= 800 mg salt) orally immediately, followed by 310 mg base (= 400 mg salt) orally at 6, 24, and 48 h Total dose: 1550-mg base (= 2000 mg salt) | 10-mg base/kg orally immediately, followed by 5-mg base/kg orally at 6, 24, and 48 h Total dose: 25-mg base/kg | Nausea, vomiting, rash, headache, dizziness, urticaria, abdominal pain, pruritusb | Safe in children and pregnant women Contraindicated if retinal or visual field change; hypersensitivity to 4-aminoquinolines Use with caution in those with impaired liver function |
Mefloquinec | P. falciparum from chloroquine-resistant areas, except Thailand-Burmese and Thailand-Cambodian border regions P. vivax from chloroquine-resistant areas | 684 mg base (= 750 mg salt) orally as initial dose, followed by 456 mg base (= 500 mg salt) orally given 6-12 h after initial dose Total dose = 1250 mg salt | 13.7 mg base/kg (= 15 mg salt/kg) orally as initial dose, followed by 9.1 mg base/kg (= 10 mg salt/kg) orally given 6-12 h after initial dose Total dose = 25 mg salt/kg | GI complaints (nausea, vomiting, diarrhea, abdominal pain), mild CNS complaints (dizziness, headache, somnolence, sleep disorders), myalgia, mild skin rash, and fatigue; moderate to severe neuropsychiatric reactions, ECG changes, including sinus arrhythmia, sinus bradycardia, first degree A-V block, QTc prolongation, and abnormal T waves | Contraindicated if hypersensitive to the drug or to related compounds; cardiac conduction abnormalities; psychiatric disorders; and seizure disorders Do not administer if patient has received related drugs (chloroquine, quinine, quinidine) less than 12 h ago |
Primaquine phosphate | Radical cure of P. vivax and P. ovale (to eliminate hypnozoites) | 30 mg base orally per day × 14 d | 0.5 mg base/kg orally per day × 14 d | GI disturbances, methemoglobinemia (self-limited), hemolysis in persons with G6PD deficiency | Must screen for G6PD deficiency prior to use Contraindicated in persons with G6PD deficiency; pregnant women Should be taken with food to minimize GI adverse effects |
Quinine sulfate (oral) | P. falciparum from chloroquine-resistant areas P. vivax from chloroquine-resistant areas | 542 mg base (650 mg salt)d orally 3 times daily × 3 d (infections acquired outside Southeast Asia) to 7 d (infections acquired in SE Asia) | 8.3 mg base/kg (10 mg salt/kg) orally 3 times daily × 3 d (infections acquired outside Southeast Asia) to 7 d (infections acquired in SE Asia) | Cinchonisme, sinus arrhythmia, junctional rhythms, atrioventricular block, prolonged QT interval, ventricular tachycardia, ventricular fibrillation (these are rare and more commonly seen with quinidine), hypoglycemia | Combine with tetracycline, doxycycline, or clindamycin, except for P. vivax infections in children <8 y or pregnant women Contraindicated in hypersensitivity including history of blackwater fever, thrombocytopenic purpura, or thrombocytopenia associated with quinine or quinidine use; many cardiac conduction defects and arrhythmiasf; myasthenia gravis; optic neuritis |
Quinidine gluconate (IV) | Severe malaria (all species, independently of chloroquine resistance) Patient unable to take oral medication Parasitemia >10% | 6.25 mg base/kg (= 10 mg salt/kg) loading dose IV over 1-2 h, then 0.0125 mg base/kg/min (0.02 mg salt/kg/min) continuous infusion for at least 24 h Alternative regimen:g | Same as adult | Cinchonism, tachycardia, prolongation of QRS and QTc intervals, flattening of T-wave (effects are often transient) Ventricular arrhythmias, hypotension, hypoglycemia | Combine with tetracycline, doxycycline, or clindamycin Contraindicated in hypersensitivity; history of blackwater fever including history of blackwater fever, thrombocytopenic purpura or thrombocytopenia associated with quinine or quinidine use; many cardiac conduction defects and arrhythmiash; myasthenia gravis; optic neuritis |
Tetracycline (oral or IV) | P. falciparum (chloroquine-resistant areas) P. vivax from chloroquine-resistant areas (with quinine/quinidine) | Oral: 250 mg 4 times daily × 7 d IV: dosage same as for oral | 25 mg/kg/d orally divided 4 times daily × 7 d IV: dosage same as for oral | See doxycycline | See doxycycline |