Recommended Treatment for Malaria
The first-line treatment for uncomplicated Plasmodium falciparum malaria is artemisinin-based combination therapy (ACT), specifically artemether-lumefantrine or dihydroartemisinin-piperaquine, while severe malaria requires immediate intravenous artesunate. 1, 2, 3
Treatment Based on Malaria Type and Severity
Uncomplicated P. falciparum Malaria
- Artemether-lumefantrine (AL) is recommended as first-line treatment with dosage of 4 tablets at 0 hours, 4 tablets at 8 hours on day 1, then 4 tablets twice daily on days 2 and 3 1, 3
- AL must be taken with a fatty meal or drink to ensure adequate absorption 1, 3
- Dihydroartemisinin-piperaquine (DP) is an effective alternative, administered as 3 tablets daily for 3 days (36-75 kg) or 4 tablets daily for 3 days (>75 kg) 1, 2
- DP must be taken in a fasting condition 1, 2
- For patients with contraindications to ACTs (e.g., risk of QTc prolongation), atovaquone-proguanil can be used as second-line treatment (4 tablets per day for 3 days for adults >40 kg) 3, 4
Uncomplicated Non-falciparum Malaria
- For P. vivax, P. ovale, and P. malariae in chloroquine-sensitive regions, chloroquine is the drug of choice 1, 5
- Chloroquine dosage: total dose of 1,500 mg (25 mg base/kg) administered over 3 days (600 mg, 600 mg, and 300 mg at 0,24, and 48 hours) 3, 5
- For P. vivax and P. ovale, treatment with primaquine or tafenoquine is necessary after blood schizontocidal treatment to eliminate liver hypnozoites and prevent relapse 1, 2
- G6PD testing is required before administering primaquine or tafenoquine 1, 2
Severe Malaria (All Species)
- Intravenous artesunate is the first-line treatment for all forms of severe malaria 1, 2, 3
- Dosage: 2.4 mg/kg IV at 0,12, and 24 hours, then daily until parasite density is <1% 1
- Once the patient improves clinically and can take oral medication, complete treatment with a full course of oral ACT 1, 3
- Monitor parasitemia every 12 hours until <1%, then every 24 hours until negative 2
- Check for delayed hemolysis on days 7,14,21, and 28 post-treatment 2, 3
Special Populations
Pregnant Women
- Artemether-lumefantrine is recommended as a treatment option in all trimesters of pregnancy 1, 2, 3
- In the first trimester, when other options are unavailable, quinine plus clindamycin can be used 2
Common Pitfalls and Caveats
- Failure to take artemether-lumefantrine with fatty food can result in subtherapeutic drug levels and treatment failure 1, 2, 3
- 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, 3
- Delayed diagnosis and treatment of P. falciparum malaria significantly increases mortality 1, 2, 3
- Not testing for G6PD deficiency before administering primaquine or tafenoquine can lead to adverse reactions 1
- Underestimating parasitemia levels can lead to incorrect diagnosis and treatment 1
- Artemisinin derivatives should not be used in the first trimester of pregnancy unless there are no effective alternatives 6
Treatment Effectiveness
- ACTs have shown efficacy rates exceeding 95% for artemether-lumefantrine, artesunate-mefloquine, and dihydroartemisinin-piperaquine 7, 6
- Artesunate-amodiaquine has shown lower efficacy in some regions and should not be used in areas with known resistance 7
- Adding a single dose of primaquine (0.75 mg/kg) substantially reduces P. falciparum gametocyte carriage, which can help reduce transmission 7