Artesunate Dosing for Complicated Malaria in Adults
For adults with complicated malaria, administer intravenous artesunate at 2.4 mg/kg body weight at 0,12, and 24 hours, then continue 2.4 mg/kg daily until the patient can tolerate oral medication. 1, 2
Initial Dosing Schedule
The WHO and CDC endorse the following precise timing for IV artesunate administration: 1, 2
- First dose: 2.4 mg/kg IV at time 0 (immediately upon diagnosis)
- 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 once daily thereafter
Duration and Transition Criteria
Continue IV artesunate until BOTH of the following conditions are met: 1
- Patient can tolerate oral medication
- Parasitemia has declined to <1%
Do not delay treatment while awaiting transfer or confirmatory testing—this is a medical emergency. 2
Completion of Treatment
After completing parenteral artesunate therapy, transition to a full 3-day course of oral artemisinin-based combination therapy (ACT): 1, 2
- Preferred options: Dihydroartemisinin-piperaquine or artemether-lumefantrine 1
- The oral ACT course is mandatory even after IV treatment to prevent recrudescence 2
Alternative if Artesunate Unavailable
If IV artesunate is not available, use IV quinine dihydrochloride as second-line: 1
- Loading dose: 20 mg salt/kg over 4 hours
- Maintenance: 10 mg/kg over 4 hours, starting 8 hours after loading dose initiation, then every 8 hours
- Complete at least 48 hours of IV treatment before switching to oral therapy 1
However, artesunate demonstrates superior outcomes with 34.7% absolute mortality reduction compared to quinine (15% vs 22% mortality), faster parasite clearance, and lower hypoglycemia risk. 3
Critical Monitoring Requirements
- Every 12 hours until decline to <1%
- Then every 24 hours until negative
Post-artesunate delayed hemolysis (PADH) surveillance: 1, 2
- Check hemoglobin, haptoglobin, and LDH at days 7,14,21, and 28
- This complication can occur even after successful parasite clearance
Continuous ICU monitoring should include: 2
- Blood glucose every 4 hours (treat if <40 mg/dL with 50 mL of 50% IV dextrose)
- Plasma lactate and bicarbonate levels
- Cardiac function, blood pressure, respiratory rate, oxygen saturation
- Urine output and renal function
- Neurological status (Glasgow Coma Scale)
Common Pitfalls to Avoid
Use restrictive fluid management to prevent pulmonary or cerebral edema without compromising renal perfusion. 1, 2
Do not use exchange blood transfusion—it has not been shown to improve outcomes and is not recommended. 1, 2
Start empiric antibiotics only if bacterial co-infection is suspected, and continue only if blood cultures are positive. 1, 2
Avoid corticosteroids—they are harmful in severe malaria. 2
Consider acetaminophen 1 gram every 6 hours for 72 hours for potential reno-protective effects in patients with acute kidney injury. 1, 2