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Guidelines for the treatment of malaria – 2 edition

5. antimalarial treatment policy

National antimalarial treatment policies should aim to offer antimalarials that are highly
effective.

5.1 criteria for antimalarial treatment policy change

The main determinant of antimalarial treatment policy is the therapeutic efficacy of the
antimalarial medicines in use. Other important determinants include: changing patterns
of malaria-associated morbidity and mortality; consumer and provider dissatisfaction
with the current policy; and the availability of alternative medicines, strategies and
approaches. Therapeutic efficacy monitoring involves the assessment of clinical and
parasitological outcomes of treatment over at least 28 days following the start of adequate
treatment to monitor for the reappearance of parasites in the blood. Reappearance of the
same genotype indicates reduced parasite sensitivity to the treatment drug.
Antimalarial treatment should be assessed on the basis of parasitological cure rates.
The duration of post-treatment follow-up is based on the elimination half-life of the
antimalarial medicine being evaluated. The current recommended duration of follow-up
is a minimum of 28 days for all antimalarial medicines, while it is extended for longer
periods of time depending on elimination half-life (42 days for combinations with
mefloquine and piperaquine). When possible, blood or plasma levels of the antimalarial
should also be measured in prospective assessments so that drug resistance can be
distinguished from treatment failures due to inadequate drug exposure.
In high-transmission settings re-infection is inevitable, but the cure of malaria (i.e.
prevention of recrudescence) is important; it benefits both the patient, by reducing
anaemia, and the community, by reducing the parasite reservoir and slowing the
emergence and spread of resistance. Slowly eliminated antimalarials provide the additional
benefit of suppressing malaria infections that are newly acquired during the period in
which residual antimalarial drug levels persist in the body. On the other hand, these
residual drug levels do provide a selection pressure for resistance. In these treatment
recommendations, the curative efficacy of the antimalarials has taken precedence over
the provision of a period of prophylaxis.

5.2 therapeutic efficacy cut-offs for changing treatment policy

A change of an antimalarial medicine recommended in the national malaria treatment
policy should be initiated if the total treatment failure proportion is ≥ 10%, as assessed
through in vivo monitoring of therapeutic efficacy. The selection of a new and/or

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