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9. Treatment of malaria caused by P. vivax, P. ovale or P. malariae

14-day regimen is significantly better at reducing relapses (6 trials, 1072 participants; OR
0.24, 95% CI 0.12–0.45). The usual adult oral dose is 15 mg base (0.25 mg/kg body weight
per day), but in South-East Asia, particularly Indonesia, and in Oceania, higher doses
(0.5 mg base/kg body weight per day) are required. Primaquine causes abdominal
discomfort when taken on an empty stomach; it should always be taken with food.

There has been debate as to whether primaquine should be given in endemic areas.
Repeated vivax malaria relapses are debilitating at any age, and so they must be prevented.
However, in situations where transmission is intense with a high rate of re-infection,
simply preventing relapses is unlikely to lower the incidence of infection or disease.
Therefore, in areas of sustained high transmission, the benefits of the widespread
deployment of primaquine are not considered to outweigh the risks associated with this
medication. In low-transmission areas, on the other hand, the benefits of primaquine
in preventing relapses will exceed its risks and its routine use to prevent relapses is
recommended in patients who are not G6PD-deficient.

box 9.2

recommendation: primaquine for the radical treatment of vivax malaria
 at least a 14-day course of primaquine is required for the radical treatment of P. vivax
Strong recommendation, very low quality evidence

GraDE evaluation (see Annex 9, table A9.7.1)
A 14-day course of primaquine significantly reduces the relapse rate of P. vivax compared to a 5-day
course (2 trials, 186 participants; RR 0.1, 95% CI 0.03–0.35; low quality evidence).

Other considerations
In addition, in clinical trials, CQ plus 14 days of primaquine has been shown to be superior to CQ alone in
reducing relapses (6 trials, 1071 participants; OR 0.24, 95% CI 0.12– 0.45). No difference has been shown
between CQ plus 5 days of primaquine and CQ alone (3 trials, 2104 participants).

Formulation. If available, administer scored tablets containing 7.5 mg or 15 mg of
primaquine. When there are no scored tablets available, 5 mg tablets can be used.
Therapeutic dose. Dose range between 0.25 and 0.5mg/kg/day primaquine once a day
for 14 days (see Annex 3, Section A3.8).

9.3.2.1 Primaquine and glucose-6-phosphate dehydrogenase deficiency

The inherited sex-linked deficiency, G6PD deficiency, is associated with some protection
against P. falciparum malaria, but there is increased susceptibility to oxidant haemolysis.
The prevalence of G6PD deficiency varies, but it can be as high as 30%; high frequencies

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