Page 175 - 80 guidelines for the treatment of malaria_opt

ANNEX 8. Treatment of severe Plasmodium falciparum malaria

was no significant difference between the two groups in mean fever clearance time, coma
recovery time and parasite clearance time (fever clearance time 31 h compared with 36 h;
coma recovery time 21 h compared with 26 h; parasite clearance time 36 h compared
with 41 h; P values not reported for any comparison).

Harms
The two systematic reviews (6, 7) and one of the subsequent RCTs (4) found no significant
difference in neurological sequelae between the artemether and quinine groups (systematic
reviews, see the Benefits section; subsequent trial 3/51 (6%) with artemether, 1/54 (2%)
with quinine, RR 3.18, 95% CI 0.34–29.56). However, in the first review, rates for the
combined outcome of death or neurological sequelae were lower for artemether than for
quinine (OR 0.77, 95% CI 0.62–0.96, P = 0.02) (6).

The second subsequent RCT found that one child treated with quinine developed
hypoglycaemia (0/20 (0%) with artemether, 1/21 (5%) with quinine (9). It reported no
neurological problems in either treatment group after 28 days of follow-up.
The third subsequent RCT found no significant difference in transient neurological
sequelae between the artemether and quinine groups (2/38 (5%) compared with 1/39
(3%) (10).

comment

The third subsequent randomized controlled trial did not use loading doses of either
artemether or quinine at the beginning of treatment (10). There was a fourth subsequent
RCT (52 people); however, it was not clear whether the participants had severe malaria
and the outcomes were poorly reported.

a8.5 Question:
Pre-referral treatment with rectal artesunate: should rectal artesunate be used A8
in preference to quinine?

summary

There are no data from trials with sufficient statistical power to assess differences in
mortality following treatment with rectal artesunate and quinine in people with moderate
or severe malaria. The objective of the trials that have been conducted was to establish the
safety and efficacy of rectal artesunate as pre-referral treatment where there is no access
to parenteral treatment. Comparisons between rectal artesunate and IV artesunate or
IV and IM quinine have been carried out to assess parasitological and clinical response
in the 12 or 24 h immediately after treatment (11, 12).
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