From the Guidelines
For a 30-year-old male with confirmed Plasmodium vivax malaria in an endemic setting, the recommended treatment is a combination of chloroquine followed by primaquine, as this approach targets both the blood stage parasites and the dormant liver stage parasites, reducing the risk of relapse and improving outcomes in terms of morbidity, mortality, and quality of life. The patient should receive chloroquine phosphate 600 mg base (1000 mg salt) orally as an initial dose, followed by 300 mg base (500 mg salt) at 6,24, and 48 hours after the first dose, achieving a total dose of 25 mg base/kg over 3 days, as recommended by 1. Following this, primaquine 30 mg base daily for 14 days should be administered to eliminate hypnozoites in the liver and prevent relapse, as supported by 1 and 1. Before starting primaquine, the patient should be tested for G6PD deficiency, as primaquine can cause hemolysis in G6PD-deficient individuals, a critical consideration highlighted in 1. If the patient is G6PD deficient, alternative dosing regimens with lower doses over a longer period may be needed under close medical supervision. The patient should be advised to take chloroquine with food to reduce gastrointestinal side effects and to complete the full course of both medications even if symptoms resolve quickly. Adequate hydration and antipyretics for fever management are also important. This regimen is in line with the most recent and highest quality evidence, prioritizing the patient's morbidity, mortality, and quality of life outcomes. Key considerations include:
- The use of chloroquine as the first-line treatment for uncomplicated P. vivax malaria in endemic settings, as per 1.
- The necessity of primaquine or tafenoquine for the prevention of relapse due to liver hypnozoites, as emphasized in 1 and 1.
- The importance of G6PD deficiency testing before initiating primaquine treatment to avoid hemolysis, a critical safety measure noted in 1.
From the FDA Drug Label
DOSAGE AND ADMINISTRATION The dosage of chloroquine phosphate is often expressed in terms of equivalent chloroquine base. ... Treatment of uncomplicated malaria due to chloroquine-sensitive Plasmodium species Adults: An initial dose of 1 g salt (= 600 mg base) followed by an additional 500 mg (= 300 mg base) after six to eight hours and a single dose of 500 mg (= 300 mg base) on each of two consecutive days. P. vivax and P. ovale: Concomitant therapy with an 8-aminoquinoline compound is necessary for treatment of the hypnozoite liver stage forms of the parasites. DOSAGE AND ADMINISTRATION Primaquine phosphate is recommended only for the radical cure of vivax malaria, the prevention of relapse in vivax malaria, or following the termination of chloroquine phosphate suppressive therapy in an area where vivax malaria is endemic. ... Primaquine phosphate should be administered concurrently in order to eradicate the exoerythrocytic parasites in a dosage of 1 tablet (equivalent to 15 mg base) daily for 14 days.
The specific treatment for a 30-year-old male patient with Plasmodium vivax (P. vivax) malaria in an endemic setting is:
- An initial dose of 1 g chloroquine phosphate (= 600 mg base) followed by an additional 500 mg (= 300 mg base) after six to eight hours and a single dose of 500 mg (= 300 mg base) on each of two consecutive days.
- Concomitant therapy with primaquine phosphate at a dosage of 1 tablet (equivalent to 15 mg base) daily for 14 days to eradicate the exoerythrocytic parasites 2 3.
From the Research
Treatment for P. vivax Malaria
The specific treatment for a 30-year-old male patient with Plasmodium vivax (P. vivax) malaria in an endemic setting involves:
- Chloroquine for the blood stage infection
- Primaquine to eradicate the liver stage of the parasite and prevent relapse of the disease 4
Primaquine Regimen
The World Health Organization recommends a 14-day course of primaquine (0.25 mg/kg/day, giving an adult dose of 15 mg/day) to prevent relapse of P. vivax malaria 4
Alternative Treatments
Alternative treatments, such as atovaquone-proguanil, have been studied for the treatment of P. vivax malaria, particularly in areas with chloroquine resistance 5, 6, 7
Efficacy of Atovaquone-Proguanil
Atovaquone-proguanil has been shown to be effective in treating P. vivax malaria, with a study in Thailand demonstrating that a sequential regimen of atovaquone-proguanil followed by primaquine was safe and effective for treatment of vivax malaria 7
Chloroquine Resistance
Chloroquine resistance is a significant concern in the treatment of P. vivax malaria, with studies indicating that resistance is present in many countries where P. vivax is endemic 8 Some key points to consider when treating P. vivax malaria include: