What is the recommended treatment regimen for uncomplicated and severe malaria?

Hospital Ward Malaria Treatment Prescription

For Uncomplicated Malaria (P. falciparum)

Artemether-Lumefantrine (Coartem) is the first-line treatment for uncomplicated malaria in hospitalized patients, with cure rates exceeding 95%. 1, 2

Standard Adult Regimen:

• Artemether-Lumefantrine 20/120 mg tablets:
  • 4 tablets at hour 0
  • 4 tablets at hour 8 (same day)
  • 4 tablets twice daily (morning and evening) on days 2 and 3
  • MUST be taken with fatty food or milk (critical for absorption) 1, 2, 3

Alternative First-Line Option:

• Dihydroartemisinin-Piperaquine:
  • 3 tablets daily for 3 days (for patients 36-75 kg)
  • 4 tablets daily for 3 days (for patients >75 kg)
  • Take on empty stomach 1, 2

Second-Line (if ACTs contraindicated):

• Atovaquone-Proguanil (Malarone):

  • 4 tablets once daily for 3 days
  • Take with fatty meal 1

• Quinine Sulfate 648 mg (two capsules) every 8 hours for 7 days PLUS Doxycycline 100 mg twice daily for 7 days (if patient ≥8 years old) 4, 5

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For Severe Malaria

Intravenous Artesunate is the only acceptable first-line treatment for severe malaria, as delayed treatment significantly increases mortality. 1, 2, 3

IV Artesunate Regimen:

• 2.4 mg/kg IV at 0,12, and 24 hours
• Then 2.4 mg/kg IV once daily until parasitemia <1% and patient can tolerate oral medication 1, 2
• Monitor parasitemia every 12 hours until <1%, then every 24 hours until negative 1, 3

Transition to Oral Therapy:

• Once parasitemia <1% and patient tolerates oral intake: Complete full 3-day course of Artemether-Lumefantrine (as above) 1, 2

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For Non-Falciparum Malaria (P. vivax, P. ovale, P. malariae)

In Chloroquine-Sensitive Regions:

• Chloroquine:
  • 600 mg base at hour 0
  • 600 mg base at 24 hours
  • 300 mg base at 48 hours
  • (Total dose: 1,500 mg base over 3 days) 1, 2

Followed by Radical Cure (P. vivax/P. ovale only):

• MUST test for G6PD deficiency first 2, 3
• If G6PD normal: Primaquine 30 mg base daily for 14 days 2
• If G6PD deficiency (30-70% activity): Primaquine 45 mg once weekly for 8 weeks 2

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Special Populations

Pregnant Women:

• Second and Third Trimester: Artemether-Lumefantrine (same dosing as above) 6, 1, 2
• First Trimester (if no alternatives): Quinine 648 mg every 8 hours for 7 days PLUS Clindamycin 300 mg every 8 hours for 7 days 3

Renal Impairment (if using Quinine):

• Loading dose: 648 mg once
• Maintenance: 324 mg every 12 hours (starting 12 hours after loading dose) 4

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Critical Monitoring Requirements

Post-Treatment Monitoring:

• Check for post-artemisinin delayed hemolysis (PADH) on days 7,14,21, and 28 after treatment 1, 2, 3
• Monitor hemoglobin/hematocrit at these intervals, as PADH occurs in 37.4% of patients 2

Drug Interactions and Contraindications:

• Both Artemether-Lumefantrine and Dihydroartemisinin-Piperaquine prolong QTc interval - avoid in patients with QTc prolongation risk or on QTc-prolonging medications 1, 2, 3
• Primaquine and Tafenoquine are absolutely contraindicated in pregnancy 2

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Common Pitfalls to Avoid

• Failure to administer Artemether-Lumefantrine with fatty food results in subtherapeutic levels and treatment failure - this is the most common error 1, 2, 3
• Do NOT give Dihydroartemisinin-Piperaquine with food - it must be taken fasting 1, 2
• Never delay treatment while awaiting confirmatory testing in suspected severe malaria - mortality increases significantly with delays 1, 3
• Always complete the full oral ACT course after IV artesunate, even if patient appears clinically well 1, 2