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Guidelines for the treatment of malaria – 2 edition

7.10.2.1 Changes in drug kinetics in malnutrition
Drug absorption may be reduced owing to diarrhoea and vomiting, rapid gut transit and
atrophy of the bowel mucosa. Absorption of intramuscular (IM) and possibly intrarectal
drugs may be slower, and diminished muscle mass may make it difficult to administer
repeated intramuscular injections. The volume of distribution of some drugs would be
expected to be larger and plasma concentrations lower. Hypoalbuminaemia, resulting
from decreased synthesis as dietary deficiency occurs, could lead to an increase in the
concentration of unbound drug; this may increase metabolic clearance, but hepatic
dysfunction may reduce the metabolism of some drugs.

7.10.2.2 Antimalarial drugs and protein energy malnutrition

There are limited data of the effect of malnutrition on chloroquine, doxycycline,
quinine, sulfadoxine-pyrimethamine and tetracycline, and not all of these studies
were conducted in patients with malaria. There is insufficient evidence to suggest that
the dosages (in mg/kg body weight) of any antimalarial should be changed in patients
with malnutrition. There are no studies in malnourished patients taking amodiaquine,
artemisinin derivatives, artemether plus lumefantrine, atovaquone plus proguanil,
clindamycin, mefloquine or primaquine.

box 7.11
recommendation: treatment of uncomplicated falciparum malaria in malnourished patients

 although there are many reasons why antimalarial pharmacokinetics may be different in
malnourished patients as compared with those who are well nourished, there is insufficient
evidence to change current mg/kg body weight dosing recommendations.

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