What is the recommended treatment for malaria?

Recommended Treatment for Malaria

For uncomplicated Plasmodium falciparum malaria, artemisinin-based combination therapies (ACTs) are the first-line treatment, specifically either artemether-lumefantrine or dihydroartemisinin-piperaquine. 1

Treatment Algorithm Based on Malaria Type and Severity

Uncomplicated P. falciparum Malaria

• First-line treatments (preferred options):

  • Dihydroartemisinin-piperaquine: For patients 36-75 kg, 3 tablets daily for 3 days; >75 kg, 4 tablets daily for 3 days (must be taken fasting) 1
  • Artemether-lumefantrine: For patients >35 kg, 4 tablets at 0 hours, 4 tablets at 8 hours on day 1; 4 tablets at 36 hours and 48 hours on day 2; 4 tablets at 60 hours and 72 hours on day 3 (must be taken with fatty meal) 1

• Second-line treatment (when ACTs are contraindicated):

  • Atovaquone-proguanil: For patients <40 kg, 3 tablets daily for 3 days; >40 kg, 4 tablets daily for 3 days (take with fatty meal) 1

• Third-line treatments:

  • Quinine sulfate plus doxycycline or clindamycin for 7 days 1
  • Mefloquine (not recommended for infections acquired in Southeast Asia or for patients with neuropsychiatric history) 1

Uncomplicated Non-falciparum Malaria (P. vivax, P. ovale, P. malariae)

• First-line treatment:

  • Chloroquine: Total dose of 25 mg base/kg over 3 days 1
  • For P. vivax from areas with known chloroquine resistance (Papua New Guinea, Indonesia, Sabah), use ACTs as listed above 1

• For P. vivax and P. ovale, additional treatment is required:

  • Primaquine or tafenoquine to eliminate liver hypnozoites (after testing for G6PD deficiency) 1
  • For patients with mild to moderate G6PD deficiency (>30% <70% activity), primaquine 45 mg once weekly for 8 weeks 1

Severe Malaria (Any Species)

• First-line treatment:
  • Intravenous artesunate 1, 2
  • Monitor parasitemia every 12 hours until decline to <1%, then every 24 hours until negative 1, 3
  • Switch to oral ACT when parasite level is <1% and patient can tolerate oral medication 1
  • Monitor for delayed hemolysis on days 7,14,21, and 28 1, 3

Special Considerations

Pregnancy

• Artemether-lumefantrine can be used in all trimesters of pregnancy as indicated by WHO and CDC 1, 3

QT Prolongation Risk

• Avoid dihydroartemisinin-piperaquine and artemether-lumefantrine in patients at risk of QT prolongation or taking medications that prolong QT interval 1, 3

Drug Resistance Concerns

• For patients from Southeast Asia (especially Greater Mekong sub-region) with potential ACT resistance, consider atovaquone-proguanil as first-line therapy 1, 3
• P. falciparum has developed resistance to chloroquine in most regions of the world, including Africa 2

Monitoring for Adverse Effects

• Post-artemisinin delayed hemolysis (PADH) has been reported in 1.9-37.4% of patients treated with ACTs 1, 3
• Monitor hemoglobin, haptoglobin, and LDH levels, particularly in patients with G6PD deficiency 3

Common Pitfalls to Avoid

• Failure to test for G6PD deficiency before administering primaquine or tafenoquine for radical cure of P. vivax/P. ovale 1
• Inadequate dosing of artemether-lumefantrine in patients with higher body weight 1
• Not providing fatty meals with artemether-lumefantrine, which can lead to decreased absorption and treatment failure 1
• Neglecting to monitor for delayed hemolysis after artemisinin treatment 1, 3
• Using chloroquine for P. falciparum without confirming the infection is from a chloroquine-sensitive region 2

The choice of antimalarial treatment should be guided by the Plasmodium species, severity of infection, local resistance patterns, and patient factors such as pregnancy status and risk of QT prolongation 1, 2.