What is the recommended treatment for uncomplicated malaria in Tanzania?

Treatment of Uncomplicated Malaria in Tanzania

Artemisinin-based combination therapies (ACTs) are the recommended first-line treatment for uncomplicated Plasmodium falciparum malaria in Tanzania, specifically artemether-lumefantrine (AL) or dihydroartemisinin-piperaquine (DP). 1, 2

First-Line Treatment Options

Artemether-Lumefantrine (AL)

• Dosing for patients >35 kg: 4 tablets at 0 hours, 4 tablets at 8 hours on day 1, then 4 tablets twice daily on days 2 and 3 (total of 24 tablets over 72 hours) 1
• Must be taken with a fatty meal or drink to enhance absorption 1
• Provides rapid parasite clearance with PCR-corrected cure rates of 94.6-100% 2
• Common adverse effects include headache, vertigo, digestive disorders, and potential QTc interval prolongation 1

Dihydroartemisinin-Piperaquine (DP)

• Dosing: 3 tablets daily for 3 days (36-75 kg) or 4 tablets daily for 3 days (>75 kg) 1
• Must be taken in fasting condition 1
• Similar efficacy to AL with PCR-corrected cure rates of 94.6-100% 2
• May provide better protection against reinfection compared to AL due to longer half-life of piperaquine 3
• Common adverse effects include headache, vertigo, digestive disorders, and QTc interval prolongation 1

Treatment Selection Considerations

• Both AL and DP demonstrate high efficacy for uncomplicated falciparum malaria in Tanzania with parasite clearance rates <0.28/h and slope half-life <3.0 hours 2
• DP may offer better protection against reinfection with rates of 17% versus 36% for AL by day 42 3
• Avoid both medications in patients at risk of QTc prolongation or taking medications that prolong QTc 1
• AL can be used in all trimesters of pregnancy as indicated by WHO and CDC 1

Second-Line Treatment Options

• Atovaquone-Proguanil is recommended as second-line treatment when ACTs are contraindicated 1, 4

  • Dosing: 4 tablets daily for 3 days (>40 kg) 1
  • Must be taken with a fatty meal or drink 1
  • Common adverse effects include digestive disorders (nausea, vomiting, diarrhea) 1

• Quinine sulfate plus doxycycline or clindamycin is considered a third-line option 1, 5

  • Quinine: 3 tablets (750 mg salt) for 3-7 days plus doxycycline 100 mg twice daily for 7 days 1
  • Contraindicated in patients with prolonged QT interval, myasthenia gravis, optic neuritis, or known hypersensitivity 6

Monitoring and Follow-up

• Monitor for parasite clearance within 72 hours of treatment initiation 2
• Follow up for at least 28 days for AL and 42 days for DP to assess cure and detect late recrudescence 2, 3
• Monitor for post-artemisinin delayed hemolysis (PADH), particularly at days 7,14,21, and 28 after treatment 1, 7
• Check for QTc prolongation in patients receiving AL or DP, especially those with risk factors 1

Special Considerations

• In cases of severe malaria (with organ dysfunction, impaired consciousness, or high parasitemia >5%), intravenous artesunate is the first-line treatment 7, 4
• For P. vivax or P. ovale infections, treatment with ACTs or chloroquine followed by primaquine is needed to prevent relapse from liver hypnozoites 1
• Test for G6PD deficiency before administering primaquine 1

Common Pitfalls to Avoid

• Failure to ensure adequate fat intake with AL administration, which can result in subtherapeutic drug levels and treatment failure 1
• Not completing the full course of treatment, which can lead to recrudescence and contribute to resistance 8, 9
• Overlooking the need for extended follow-up, as recrudescence can occur after day 28 2, 3
• Failing to recognize signs of severe malaria requiring parenteral therapy 7