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ANNEX 8. Treatment of severe Plasmodium falciparum malaria

a8.1 Question:
Is artesunate superior to quinine in treating severe malaria?

Background
Artesunate was recommended as an alternative to quinine for treating severe malaria in
the first edition of the WHO guidelines for the treatment of malaria.

GraDE approach

Artesunate was compared to quinine using meta-analyses of head-to-head RCTs (search
date: January 2007).
1. Is artesunate superior to quinine in treating severe malaria? (See GRADE Table
A8.1.)

When assessing this evidence the WHO GRADE panel considered the following factors
to be important:
• all six studies included in the review were conducted in Asia;
• one large trial enrolling both adults and children provides most of the data but
outcomes were not reported separately for children;
• most deaths from severe malaria occur in African children;
• children present with a different picture of severe malaria compared to adults;

• five trials used intravenous artesunate and one trial used intramuscular artesunate.

Other considerations
In contrast to quinine, administration of artesunate does not require cardiac monitoring
and, therefore, may be a more practical option in resource-poor settings.
A8
Decision

On the basis of these tables, the WHO GRADE panel made a strong recommendation
that artesunate should be used in preference to quinine for the treatment of severe
malaria in Asia.

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