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Guidelines for the treatment of malaria – 2 edition

are found only in areas where malaria is or has been endemic. There are a large number
of different genotypes, each with different levels of deficiency. Primaquine is an oxidant
and causes variable haemolysis in G6PD-deficient individuals. Primaquine also causes
methemoglobinaemia. The severity of haemolytic anaemia is related to primaquine
dosing and the variant of the G6PD enzyme. Fortunately, primaquine is eliminated
rapidly and so haemolysis is self-limiting provided no further drug is taken. Screening
for G6PD deficiency is not generally available outside hospitals, although rapid tests
are under development. Many patients are, therefore, unaware of their G6PD status. If
a patient is known to be severely G6PD deficient, then primaquine should not be given.
For the majority of patients with mild variants of the deficiency, primaquine should be
given in a dose of 0.75 mg base/kg body weight once a week for eight weeks. If significant
haemolysis occurs on treatment, then primaquine should be stopped.
Primaquine is contraindicated in pregnant women and children less than four years of
age. There is no reliable data on the excretion of primaquine in breast milk to warrant
it being contraindicated in women who are breast feeding, however, it is recommended
that primaquine use in this group of patients should be medically supervised.

box 9.3
Summary of recommendations on the treatment of uncomplicated vivax malaria

 chloroquine 25 mg base/kg body weight divided over 3 days, combined with primaquine 0.25 mg
base/kg body weight, taken with food once daily for 14 days is the treatment of choice for
chloroquine-sensitive infections. in oceania and south-east asia, the dose of primaquine should
be 0.5 mg/kg body weight.
 acts combined with primaquine for chloroquine-resistant vivax malaria.

 in mild-to-moderate G6pd deficiency, primaquine 0.75 mg base/kg body weight should be given
once a week for 8 weeks. in severe G6pd deficiency, primaquine is contraindicated and should
not be used.

 Where act (exception as+sp) has been adopted as the first-line treatment for P. falciparum
malaria, it may also be used for P. vivax malaria in combination with primaquine for radical cure.
artesunate plus sulfadoxine-pyrimethamine is not effective against P. vivax in many places.

9.4 treatment of severe P. vivax malaria

Although P. vivax malaria is considered to be benign malaria, with a very low case-fatality
ratio, it may still cause a severe and debilitating febrile illness. It can also occasionally
result in severe disease, as in P. falciparum malaria. Severe P. vivax malaria manifestations

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