How should I give a stat intravenous artesunate dose (2.4 mg/kg) for a patient with severe Plasmodium falciparum malaria?

How to Administer Stat Intravenous Artesunate

For severe Plasmodium falciparum malaria, immediately administer intravenous artesunate at 2.4 mg/kg body weight as the first dose (time 0), followed by repeat doses at 12 hours and 24 hours, then once daily thereafter until the patient can tolerate oral therapy and parasitemia falls below 1%. 1, 2

Immediate Administration Protocol

Dose Calculation and Preparation

• Calculate the exact dose: 2.4 mg/kg of actual body weight 1, 3
• Reconstitute the artesunate powder according to manufacturer instructions (typically with 5% sodium bicarbonate solution, then dilute with 5% dextrose or normal saline) 1
• Administer as an intravenous bolus injection over 1-2 minutes or as a short infusion 4, 3

Critical Timing Sequence

• First dose (0 hours): 2.4 mg/kg IV immediately upon diagnosis—do not delay for transfer or additional testing 5, 1
• Second dose (12 hours): 2.4 mg/kg IV exactly 12 hours after the first dose 1, 2
• Third dose (24 hours): 2.4 mg/kg IV at 24 hours 1, 2
• Subsequent doses: 2.4 mg/kg IV once daily (every 24 hours) until switching criteria are met 1

When to Switch to Oral Therapy

Required Criteria (All Must Be Met)

• Patient is hemodynamically stable and conscious 1
• Patient can tolerate oral intake without vomiting 1
• Parasitemia has declined to <1% of red blood cells 1, 2
• Minimum of three IV doses completed (at 0,12, and 24 hours) 1

Oral Completion Regimen

• Immediately start a full 3-day course of artemisinin-based combination therapy (ACT) 1, 2
• Preferred options: artemether-lumefantrine or dihydroartemisinin-piperaquine 1
• The oral ACT must be given for the complete 3 days regardless of how many IV artesunate days were administered 1

Essential Monitoring During Treatment

Parasitemia Surveillance

• Check peripheral blood smear every 12 hours until parasitemia drops below 1% 5, 1, 2
• Once <1%, check every 24 hours until negative 5, 1, 2
• An initial increase in parasite density within the first 24 hours does not indicate treatment failure 1

Metabolic and Hematologic Monitoring

• Monitor blood glucose frequently—hypoglycemia is common and potentially fatal 2
• Treat hypoglycemia immediately with 50 mL of 50% IV dextrose if detected or suspected 2
• Check complete blood count, liver function, renal function, and lactate daily 5, 2

Post-Treatment Surveillance

• Screen for post-artesunate delayed hemolysis (PADH) at days 7,14,21, and 28 after completing IV artesunate 1, 2
• Check hemoglobin, haptoglobin, and lactate dehydrogenase at each timepoint 1, 2
• PADH occurs in approximately 10-15% of patients treated with IV artesunate 1

Common Pitfalls to Avoid

• Do not delay the first dose for any reason—treatment is a medical emergency and should begin immediately, even before hospital transfer 5, 1
• Do not stop IV artesunate after only three doses if the patient cannot yet tolerate oral intake; continue once-daily IV dosing until oral tolerance is achieved 1
• Do not switch to oral ACT while parasitemia remains ≥1%, as adequate parasite clearance has not been achieved 1
• Do not shorten the oral ACT regimen; a complete 3-day course is mandatory after IV artesunate cessation 1
• Do not use restrictive fluid management to the point of causing hypotension—balance is needed to avoid both pulmonary edema and inadequate perfusion 2

Alternative if Artesunate Unavailable

If IV artesunate is not available, use intravenous quinine dihydrochloride as second-line therapy 1, 2:

• Loading dose: 20 mg salt/kg over 4 hours 1, 2
• Maintenance: 10 mg/kg over 4 hours every 8 hours, starting 8 hours after initiation of loading dose 1, 2
• Omit loading dose if patient received quinine or mefloquine in the previous 24 hours 2
• Switch to oral therapy after completing at least 48 hours of IV treatment when feasible 2