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Guidelines for the treatment of malaria – 2 edition

it is recommended that patients be treated with the first dose of one of the recommended
treatments before referral (unless the referral time is less than 6 h). Recommended pre-
referral treatment options include intramuscular artesunate, artemether, or quinine, or
rectal artesunate (see Annex 8, Section A8.5). Evidence from recent studies demonstrates
that in situations where parenteral medication is not possible and intramuscular injection
impractical, using a single dose of rectal artesunate as pre-referral treatment reduces the
risk of death or permanent disability in young children.

Box 8.2
Recommendation: pre-referral treatment for severe P. falciparum malaria

 if complete treatment for severe malaria (as recommended in Section 8.4) is not possible,
patients with severe malaria should be given pre-referral treatment and referred immediately
to an appropriate facility for further treatment.
– The following are options for pre-referral treatment:
• rectal artesunate • quinine IM • artesunate IM • artemether IM.
– In young children of less than 5 years of age, the use of rectal artesunate (10 mg/kg) has been shown
to reduce the risk of death and permanent disability.

8.6.1 Pre-referral and continued treatment with rectal artemisinins
The administration of an artemisinin derivative by the rectal route as pre-referral
treatment is feasible and acceptable even at the community level.
There is insufficient evidence to show whether rectal artesunate is as good as intravenous
or intramuscular options in the management of severe malaria. The recommendation,
therefore, is to use artesunate or artemisinin suppositories only as pre-referral treatment
and to refer the patient to a facility where complete parenteral treatment with artesunate,
quinine or artemether can be instituted. If, however, referral is impossible, rectal
treatment should be continued until the patient can tolerate oral medication; at this
point, a full course of the recommended ACT for uncomplicated malaria in the locality
can be administered.

8.6.2 Dosing for antimalarials given by rectal route

8.6.2.1 Initial (pre-referral) treatment with rectal artesunate
The 10 mg/kg body weight single dose of artesunate suppository should be administered
rectally as soon as the presumptive diagnosis of severe malaria is made. In the event
that an artesunate suppository is expelled from the rectum within 30 min of insertion,
a second suppository should be inserted and, especially in young children, the buttocks
should be held together for 10 min to ensure retention of the rectal dose of artesunate.
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