Primary Dosing for Falciparum Malaria Treatment
For uncomplicated Plasmodium falciparum malaria, the first-line treatment is artemether-lumefantrine with a dosage of 4 tablets (20 mg/120 mg per tablet) at 0 hours, 4 tablets at 8 hours on day 1, then 4 tablets twice daily on days 2 and 3, taken with a fatty meal. 1
First-Line Treatment Options
Artemether-lumefantrine (AL) is a preferred first-line treatment for adults >35 kg with uncomplicated P. falciparum malaria, administered as 4 tablets at 0 hours, 4 tablets at 8 hours on day 1, followed by 4 tablets twice daily on days 2 and 3 (total of 24 tablets over 72 hours) 1
Dihydroartemisinin-piperaquine (DHA-PPQ) is another first-line option for adults, administered as 3 tablets daily for 3 days (for patients 36-75 kg) or 4 tablets daily for 3 days (for patients >75 kg) 1
Both medications must be taken appropriately to ensure efficacy - AL with fatty food or drink, and DHA-PPQ in a fasting condition 1, 2
Second-Line Treatment Options
Atovaquone-Proguanil (250 mg + 100 mg) is recommended as a second-line treatment, with dosing of 4 tablets daily for 3 days for adults >40 kg, taken with a fatty meal or drink 1
Mefloquine (250 mg salt/228 mg base) is considered a third-line option, administered as 3 tablets (750 mg salt) on day 1, followed by 2 tablets (500 mg salt) after 8-12 hours 1
Quinine sulfate plus doxycycline or clindamycin is another third-line option, with quinine dosing of 648 mg (two capsules) every 8 hours for 7 days, taken with food 1, 3
Efficacy and Evidence
Clinical trials have demonstrated high efficacy rates for artemisinin-based combination therapies (ACTs) in treating uncomplicated P. falciparum malaria, with cure rates ≥94.9% 1
A study in Uganda showed artemether-lumefantrine achieved a 99.3% cure rate for uncomplicated P. falciparum malaria 1
The six-dose regimen of artemether-lumefantrine has been shown to be significantly more effective than the four-dose regimen, with adjusted 28-day cure rates of 96.9-99.12% compared to 83.3% 4
Important Considerations and Precautions
Both artemether-lumefantrine and dihydroartemisinin-piperaquine can cause QTc interval prolongation and should be avoided in patients at risk of QTc prolongation or taking medications that prolong QTc 1, 2
For severe malaria, intravenous artesunate is the preferred first-line treatment (2.4 mg/kg IV at 0,12, and 24 hours, then daily) rather than oral therapy 1, 2
Artemether-lumefantrine can be used in all trimesters of pregnancy as recommended by WHO and CDC 1
Failure to ensure adequate fat intake with artemether-lumefantrine administration can result in subtherapeutic drug levels and treatment failure 5, 2
Monitoring and Follow-up
Monitor for post-artemisinin delayed hemolysis, particularly at days 7,14,21, and 28 after treatment 5, 2
Parasite clearance should be achieved within 72 hours of treatment initiation with effective therapy 6
For patients with severe chronic renal impairment receiving quinine, a modified dosing regimen is recommended: one loading dose of 648 mg followed 12 hours later by maintenance doses of 324 mg every 12 hours 3