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8. Treatment of severe P. falciparum malaria

8.6.2.2 Artemether
Doses used have been variable and empiric: 10–40 mg/kg body weight (at 0, 4 or 12, 24, 48 and
72 h). Some studies have given a maintenance dose of one to two thirds of the initial dose.

8.6.2.3 Quinine
The intrarectal dose used in treatment trials in Africa was either 12 mg/kg BW quinine
®
base (as Quinimax , a cinchona alkaloid combination containing 96.1% quinine, 2.5%
quinidine, 0.68% cinchonine, and 0.67% cinchonidine as gluconate salts) every 12 h
without a loading dose, or 8 mg/kg BW every 8 h without a loading dose. The retention
and absorption of quinine is dependent on pH. Results with gluconate salts (pH 4.5)
cannot be extrapolated to more acidic solutions (such as the dihydrochloride salt, pH 2).

Box 8.3

Summary of recommendations on the tReatment oF SeveRe FalciPaRum malaRia

 Severe malaria is a medical emergency. after rapid clinical assessment and confirmation of the
diagnosis, full doses of parenteral antimalarial treatment should be started without delay with
any effective antimalarial first available.
 For adults, artesunate 2.4 mg/kg BW iv or im given on admission (time = 0), then at 12 h and
24 h, then once a day is the recommended treatment. artemether, or quinine, is an acceptable
alternative if parenteral artesunate is not available: artemether 3.2 mg/kg BW im given on
admission then 1.6 mg/kg BW per day ; or quinine 20 mg salt/kg BW on admission (iv infusion
or divided im injection), then 10 mg/kg BW every 8 h; infusion rate should not exceed 5 mg salt/
kg BW per hour.

 For children, artesunate 2.4 mg/kg BW iv or im given on admission (time = 0), then at 12 h and
24 h, then once a day is the recommended treatment. artemether, or quinine, is an acceptable
alternative if parenteral artesunate is not available: artemether 3.2 mg/kg BW im given on
admission then 1.6 mg/kg BW per day ; or quinine 20 mg salt/kg BW on admission (iv infusion
or divided im injection), then 10 mg/kg BW every 8 h; infusion rate should not exceed 5 mg salt/
kg BW per hour.
 Give parenteral antimalarials in the treatment of severe malaria for a minimum of 24 h, once
started (irrespective of the patient’s ability to tolerate oral medication earlier), and, thereafter,
complete treatment by giving a complete course of:
– artemether plus lumefantrine,
– artesunate plus amodiaquine,
– dihydroartemisinin plus piperaquine,
– artesunate plus sulfadoxine-pyrimethamine,
– artesunate plus clindamycin or doxycycline,
– quinine plus clindamycin or doxycycline.
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