Artesunate Oral Tablet Dosing for Uncomplicated Malaria
For uncomplicated P. falciparum malaria in adults, oral artesunate is dosed at 4 mg/kg/day for 3 days, and must be followed by a full course of a partner drug (typically mefloquine 25 mg/kg or doxycycline 100 mg twice daily for 7 days) to prevent recrudescence. 1, 2
Dosing Regimens by Weight
Artesunate Monotherapy (Initial Phase)
- Standard dose: 4 mg/kg body weight once daily for 3 days 3, 2, 4
- Alternative regimen: 4 mg/kg on day 1, then 2 mg/kg daily on days 2-5 (5-day course) 5
Combination Therapy (Preferred)
Artesunate + Mefloquine (Most Effective for Resistant Areas)
- Artesunate: 4 mg/kg/day for 3 days
- Mefloquine: Either 8 mg/kg/day for 3 days (co-administered with artesunate) OR 15 mg/kg on day 1 plus 10 mg/kg on day 2 3, 2, 4
- Total mefloquine dose: 25 mg/kg over the treatment course 4
Artesunate + Doxycycline
- Artesunate: 4 mg/kg/day for 3 days
- Doxycycline: 100 mg twice daily for 7 days (in patients ≥8 years old) 2
Critical Clinical Considerations
Why Combination Therapy is Essential
Artesunate monotherapy, even for 5 days, yields only a 90% cure rate and should not be used alone. 5 The addition of a partner drug is mandatory to achieve cure rates exceeding 98% and prevent the development of artemisinin resistance. 4
Severe vs. Uncomplicated Malaria Distinction
- Oral artesunate is only for uncomplicated malaria 1, 2
- For severe malaria, intravenous artesunate at 2.4 mg/kg is required at 0,12, and 24 hours, then daily until parasitemia <1% and oral intake is tolerated 6, 1
- Patients with hyperparasitemia (>4% parasitemia) can be treated with oral artesunate if they have no vital organ dysfunction 7
Monitoring Requirements
- Parasitemia should be checked on day 3 (expect 75% reduction) and day 7 (expect negative result) 6
- Post-artesunate delayed hemolysis (PADH) monitoring is essential: check hemoglobin, haptoglobin, and LDH on days 7,14,21, and 28, as PADH occurs in up to 37.4% of patients 6, 8
Geographic Resistance Considerations
For patients from the Greater Mekong sub-region (Southeast Asia), artesunate-based combinations may have reduced efficacy due to artemisinin resistance. 6, 8 In these cases, consider alternative regimens such as atovaquone-proguanil. 6, 1
Administration Details
- Oral artesunate can be taken with or without food 2, 5
- When combined with mefloquine, giving mefloquine on day 2 (rather than day 1) significantly reduces vomiting (RR 0.40) 4
- Fever clearance typically occurs within 19-32 hours, and parasite clearance within 36-43 hours 3, 7
Common Pitfalls to Avoid
- Never use artesunate monotherapy without a partner drug - this promotes resistance and has unacceptably high failure rates 4, 5
- Do not confuse oral dosing (4 mg/kg/day) with IV dosing (2.4 mg/kg) - these are different regimens for different disease severity 6, 2
- Do not skip PADH monitoring - hemolysis can occur weeks after treatment and may be severe 6, 8