What are the adult doses of all anti-malarial medications, including chloroquine, mefloquine, doxycycline, atovaquone-proguanil, and artemisinin-based combination therapies (ACTs), for an adult patient with normal renal function?

Adult Antimalarial Drug Dosing

For uncomplicated P. falciparum malaria in adults, artemether-lumefantrine is the first-line treatment at 4 tablets (80mg/480mg) at 0 and 8 hours on day 1, then 4 tablets twice daily on days 2-3 with fatty food, while severe malaria requires IV artesunate 2.4 mg/kg at 0,12, and 24 hours, then daily. 1

Uncomplicated Malaria Treatment

Artemisinin-Based Combination Therapies (First-Line)

Artemether-Lumefantrine (Coartem)

• Adults ≥35 kg: 4 tablets (80mg artemether/480mg lumefantrine) at 0 hours, 4 tablets at 8 hours on day 1, then 4 tablets twice daily on days 2 and 3 2, 1
• Must be taken with fatty meal or drink to optimize absorption 1
• Cure rate exceeds 96-98.4% 2, 1

Dihydroartemisinin-Piperaquine (DHA-PPQ)

• 36-75 kg: 3 tablets daily for 3 days 1
• >75 kg: 4 tablets daily for 3 days 1
• Preferred alternative to artemether-lumefantrine, particularly for P. vivax due to longer half-life of piperaquine 2, 1

Atovaquone-Proguanil (Malarone)

• Adults >40 kg: 4 adult tablets (250mg/100mg) once daily for 3 consecutive days 2, 3
• 31-40 kg: 3 adult tablets daily for 3 days 2
• Take with food or milky drink 3
• Overall cure rate >98% 4
• If vomiting occurs within 1 hour, repeat the dose 3

Non-Artemisinin Options

Mefloquine (Lariam)

• Treatment dose: 15 mg base/kg (max 750 mg) orally once, then 10 mg base/kg (max 500 mg) 8-24 hours later 2
• Contraindicated in patients with history of seizures, epilepsy, or psychiatric disorders 2
• Neuropsychiatric side effects occur in approximately 0.01% but may be higher in practice 2

Quinine Sulfate (for chloroquine-sensitive regions)

• Adults: 650 mg (10 mg/kg, max 650 mg) orally every 8 hours for 3-7 days 2
• PLUS doxycycline 100 mg orally twice daily for 7 days 2
• OR clindamycin 300-450 mg orally every 8 hours for 7 days 2
• Total 7-day course appropriate if quinine used throughout 2

Chloroquine Phosphate (for chloroquine-sensitive P. falciparum, P. vivax, P. ovale, P. malariae)

• Loading dose: 1000 mg (600 mg base) orally once 2, 5
• Then: 500 mg (300 mg base) at 6,24, and 48 hours 2, 5
• Total dose: 2500 mg chloroquine phosphate (1500 mg base) = 25 mg/kg base over 3 days 2

Severe Malaria Treatment

Intravenous Artesunate (First-Line)

• Loading: 2.4 mg/kg IV at 0,12, and 24 hours 2, 1, 5
• Maintenance: 2.4 mg/kg IV daily until parasite density <1% and patient can take oral medication 2, 1
• Switch to full oral course (artemether-lumefantrine, DHA-PPQ, atovaquone-proguanil, or mefloquine) once able to tolerate oral therapy 2
• Do not switch before completing 48 hours of IV treatment 2

Intravenous Quinine (Second-Line if artesunate unavailable)

• Loading dose: 20 mg salt/kg IV over 4 hours 2, 5
• Maintenance: 10 mg/kg IV over 4 hours every 8 hours, starting 8 hours after initiation of loading dose 2, 5
• Omit loading dose if patient received mefloquine prophylaxis in previous 24 hours or treatment dose within 3 days 2
• If IV quinine continued >48 hours with renal failure, reduce dose by one-third 2
• Monitor for QT prolongation and hypoglycemia due to insulin release 2

Quinidine Gluconate (alternative in settings where quinine unavailable)

• Loading dose: 6.25 mg base/kg IV over 1-2 hours 2
• Maintenance: 0.0125 mg/kg/minute continuous infusion 2
• Duration: 7 days for Southeast Asia/Oceania exposure; otherwise 3 days 2
• PLUS doxycycline 100 mg every 12 hours for 7 days OR clindamycin 20 mg/kg/day divided every 8 hours for 7 days 2
• Requires cardiac monitoring; do not give as IV bolus 2

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

Primaquine (for radical cure of liver hypnozoites)

• G6PD normal patients: 30 mg base daily for 14 days 5, 6
• Intermediate G6PD deficiency (30-70% activity, non-Mediterranean A- variant): 0.75 mg/kg weekly (max 45 mg) for 8 weeks with close hemolysis monitoring 2, 6
• Contraindicated: G6PD deficiency <30%, Mediterranean B- variant, pregnancy, breastfeeding 2, 6
• Mandatory: Quantitative G6PD testing before administration 5, 6

Tafenoquine (alternative for radical cure)

• Adults with G6PD ≥70%: Single dose (specific dose not provided in evidence but requires quantitative G6PD testing) 2
• Not available outside United States or Australia 2
• FDA restricts coadministration with chloroquine only 2

Prophylaxis Dosing

Atovaquone-Proguanil

• Adults: 1 tablet (250mg/100mg) daily 3
• Start 1-2 days before travel, continue during stay, and for 7 days after leaving endemic area 3

Mefloquine

• Adults: 250 mg weekly 2
• Start 1-2 weeks before travel, continue weekly during travel, and for 4 weeks after departure 2

Doxycycline

• Adults: 100 mg daily 2
• Start 1-2 days before travel, continue daily during travel, and for 4 weeks after departure 2
• Photosensitization risk; avoid excessive sun exposure 2

Chloroquine

• Adults: 300 mg base (500 mg chloroquine phosphate) weekly 2
• Start 1-2 weeks before travel, continue weekly during travel, and for 4 weeks after departure 2

Special Populations

Renal Impairment

• Atovaquone-proguanil: Contraindicated for prophylaxis if creatinine clearance <30 mL/min; may use with caution for treatment 3
• Proguanil alone (if used): Dose adjustment required based on creatinine clearance 2
  • CrCl >60: 200 mg daily
  • CrCl 20-60: 150 mg daily
  • CrCl 10-20: 100 mg daily
  • CrCl <10: 50 mg every other day 2

Hepatic Impairment

• No dose adjustment needed for mild-moderate hepatic impairment with atovaquone-proguanil 3
• Mefloquine unsuitable for liver impairment 2

Critical Monitoring Points

• Monitor blood glucose with quinine/quinidine due to hypoglycemia risk 2
• Cardiac monitoring required for quinidine; watch for QT prolongation 2
• Monitor for hemolysis with primaquine (dark urine, jaundice, fatigue) 5
• Confirm parasite clearance with follow-up blood smears 5
• Clinical improvement expected within 48 hours of treatment initiation 5