Intravenous Artesunate Dosing for Plasmodium falciparum Malaria
For treatment of complicated Plasmodium falciparum malaria, intravenous artesunate should be administered at 2.4 mg/kg body weight at 0,12, and 24 hours, then continued at 2.4 mg/kg daily until the patient can take oral medication. 1, 2, 3
Dosing Regimen Details
- The first-line treatment for complicated P. falciparum malaria is intravenous artesunate, which should be administered immediately as a medical emergency 2, 3
- The recommended dosing schedule is:
- Initial dose: 2.4 mg/kg IV at 0 hours
- Second dose: 2.4 mg/kg IV at 12 hours
- Third dose: 2.4 mg/kg IV at 24 hours
- Subsequent doses: 2.4 mg/kg IV daily 1
- Continue IV artesunate until:
- Patient can tolerate oral medication AND
- Parasite density has decreased to <1% 1
Transition to Oral Therapy
- Once the patient improves and can take oral medication, complete treatment with a full course of oral artemisinin-based combination therapy (ACT) 2, 3
- The transition to oral therapy should occur after at least 24 hours of IV artesunate, but only when the patient is clinically improved 2
- Preferred oral options include dihydroartemisinin-piperaquine or artemether-lumefantrine 1
Monitoring During Treatment
- Monitor parasitemia every 12 hours until it declines to <1%, then every 24 hours until negative 2, 3
- Monitor complete blood count, renal function, liver function, and metabolic parameters daily 3
- Check for post-artesunate delayed hemolysis (PADH) by monitoring hemoglobin, haptoglobin, and lactate dehydrogenase at days 7,14,21, and 28 after treatment initiation 2
Alternative Treatment Options
- If intravenous artesunate is unavailable, intravenous quinine dihydrochloride can be used as a second-line option 1
- Quinine dosing: 20 mg salt/kg loading dose over 4 hours, followed by 10 mg/kg over 4 hours starting 8 hours after initiation, and then every 8 hours 1
- Switch to oral therapy as soon as feasible, but not before completing 48 hours of IV treatment 1
Special Considerations
- Artesunate provides faster parasite clearance and shorter ICU stays compared to quinine 2, 3
- Use restrictive fluid management to avoid pulmonary or cerebral edema 2, 3
- Consider acetaminophen (1g every 6 hours for 72 hours) for potential reno-protective effects in patients with acute kidney injury 2
- Start antibiotics if bacterial co-infection is suspected, but continue only if blood cultures are positive 2
This dosing regimen is supported by multiple international guidelines and has been shown to be effective in reducing mortality from severe malaria compared to other treatments.