Management of Plasmodium falciparum Malaria
Artemisinin-based combination therapies (ACTs) are the first-line treatment for uncomplicated Plasmodium falciparum malaria, with dihydroartemisinin-piperaquine or artemether-lumefantrine as the preferred options. 1, 2, 3
Treatment Algorithm Based on Disease Severity
Uncomplicated P. falciparum Malaria
- First-line treatment options include:
- Artemether-lumefantrine (AL): 4 tablets at 0 hours, 4 tablets at 8 hours on day 1, then 4 tablets twice daily on days 2 and 3, must be taken with a fatty meal or drink 1, 2, 3
- Dihydroartemisinin-piperaquine (DP): 3 tablets daily for 3 days (36-75 kg) or 4 tablets daily for 3 days (>75 kg), must be taken in fasting condition 1, 2, 4
- Both first-line options have potential adverse effects including headache, vertigo, digestive disorders, and QTc interval prolongation 1, 2
- Second-line treatment when ACTs are contraindicated:
Severe P. falciparum Malaria
- Intravenous artesunate is the first-line treatment for severe malaria 1, 3
- Administer for 3 doses and monitor parasitemia every 12 hours until <1%, then every 24 hours until negative 1
- Once the patient improves clinically (parasitemia <1%) and can tolerate oral medication, switch to a full course of oral ACT 1, 3
- Patients should be admitted to the intensive care unit for management of complications 1
Special Considerations
Pregnancy
- Artemether-lumefantrine can be used in all trimesters of pregnancy as indicated by WHO and CDC 1, 4
- For first trimester, when other options are unavailable, quinine plus clindamycin may be considered 3
Drug Resistance
- In areas with known artemisinin resistance (Greater Mekong sub-region), triple artemisinin-based combination therapies (TACTs) may be considered 5, 6
- Dihydroartemisinin-piperaquine plus mefloquine has shown high efficacy in areas with resistance to dihydroartemisinin-piperaquine 5
Monitoring and Follow-up
- Monitor for clinical improvement and parasite clearance 1
- Check for post-artemisinin delayed hemolysis (PADH) on days 7,14,21, and 28 after treatment 1, 4
- Monitor full blood count, hepatic, kidney, and metabolic parameters daily in severe cases 1
Common Pitfalls to Avoid
- Failure to ensure adequate fat intake with artemether-lumefantrine can result in subtherapeutic drug levels and treatment failure 2, 4
- Delayed diagnosis and treatment of P. falciparum malaria is associated with increased mortality 3
- Overlooking QTc prolongation risk in patients receiving AL or DP, especially those with risk factors or taking medications that prolong QTc 2, 3
- Failing to recognize criteria for severe malaria requiring parenteral therapy (impaired consciousness, respiratory distress, severe anemia, jaundice, renal impairment, hypoglycemia, parasitemia >2-5%) 1
Treatment Efficacy
- All recommended ACTs achieve PCR-adjusted failure rates of <10% in most study sites, in line with WHO recommendations 7
- Dihydroartemisinin-piperaquine has shown superior efficacy compared to artemether-lumefantrine in some African studies (PCR adjusted treatment failure: RR 0.39,95% CI 0.24 to 0.64) 7