What is the recommended dose for malaria treatment?

Malaria Treatment Dosing

For uncomplicated P. falciparum malaria, use artemether-lumefantrine 4 tablets at 0 hours, 4 tablets at 8 hours on day 1, then 4 tablets twice daily on days 2 and 3 (total 24 tablets over 72 hours), taken with a fatty meal or drink. 1, 2

First-Line Treatment for Uncomplicated P. falciparum Malaria

Artemether-Lumefantrine (Preferred)

• Dosing for adults >35 kg: 4 tablets (80mg artemether/480mg lumefantrine) at hour 0,4 tablets at hour 8, then 4 tablets at hours 36,48,60, and 72 (total 24 tablets over 3 days) 1
• Critical administration requirement: Must be taken with a fatty meal or drink to ensure adequate absorption—failure to do so results in subtherapeutic drug levels and treatment failure 1, 2, 3
• Cure rates exceed 96-98.4% for uncomplicated falciparum malaria 2, 4
• Can be used in all trimesters of pregnancy per WHO and CDC guidelines 1, 3

Dihydroartemisinin-Piperaquine (Alternative First-Line)

• Dosing for 36-75 kg: 3 tablets daily for 3 days 1, 2
• Dosing for >75 kg: 4 tablets daily for 3 days 1, 2
• Must be taken in fasting condition (opposite of artemether-lumefantrine) 2, 3
• Superior to artemether-lumefantrine in preventing P. vivax recurrence (RR 0.32,95% CI 0.24-0.43) 5

Second-Line Treatment Options

Atovaquone-Proguanil

• Dosing for <40 kg: 3 tablets (250mg/100mg) per day for 3 days 1
• Dosing for >40 kg: 4 tablets per day for 3 days 1, 4
• Must be taken with a fatty meal or drink 1, 4
• Use when ACTs are contraindicated (e.g., QTc prolongation risk) 1, 3

Quinine Plus Doxycycline (Third-Line)

• Quinine sulfate: 3 tablets (750 mg salt) three times daily for 3-7 days 1, 4
• Doxycycline: 100 mg twice daily for 7 days 1, 6
• Alternative: Quinine plus clindamycin 20 mg/kg every 8 hours for 7 days 1, 4
• Avoid quinine for P. falciparum acquired in Southeast Asia due to resistance 1, 4

Treatment for Severe Malaria

Intravenous Artesunate (First-Line)

• Dosing: 2.4 mg/kg IV at 0,12, and 24 hours, then 2.4 mg/kg daily until parasite density <1% and patient can take oral medication 1, 2, 4
• Once improved clinically, complete treatment with full course of oral ACT 1, 3, 4
• Monitor for post-artemisinin delayed hemolysis (PADH) on days 7,14,21, and 28 after treatment 2, 3, 4

Intravenous Quinine (Second-Line)

• Loading dose: 20 mg salt/kg over 4 hours 1, 4
• Maintenance: 10 mg/kg over 4 hours starting 8 hours after initiation, then every 8 hours 1, 4
• Switch to oral therapy after completing minimum 48 hours IV treatment when feasible 1

Treatment for Non-Falciparum Species

P. vivax, P. ovale, P. malariae (Chloroquine-Sensitive Regions)

• Chloroquine: 4 tablets (1000 mg salt) initially, then 2 tablets (500 mg salt) at 6,24, and 48 hours 1
• ACTs (artemether-lumefantrine or dihydroartemisinin-piperaquine) are alternative first-line options 1, 7

Anti-Relapse Treatment for P. vivax and P. ovale

• Primaquine: 2 tablets (30 mg base) daily for 14 days 1
• Tafenoquine: Single 300 mg dose 1
• Critical safety requirement: Must test for G6PD deficiency before administering—both drugs cause severe hemolytic anemia in G6PD-deficient patients 1, 3
• Contraindicated in pregnancy 3

Critical Pitfalls to Avoid

• Inadequate fat intake with artemether-lumefantrine is the most common cause of treatment failure—absorption is markedly reduced without fatty food 1, 2, 3
• QTc prolongation risk: Both artemether-lumefantrine and dihydroartemisinin-piperaquine prolong QTc interval—avoid in patients with cardiac risk factors or on QTc-prolonging medications 1, 2, 3
• Delayed treatment of P. falciparum significantly increases mortality 2, 3
• Quinine adverse effects include cinchonism (tinnitus, vertigo, headache), hypoglycemia, and thrombocytopenia—requires close monitoring 1, 2, 4