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Guidelines for the treatment of malaria – 2 edition

Benefits
Two randomized, open-label Phase II and three randomized open label Phase III studies
have been conducted in people with moderately severe malaria, i.e. patients who could
not take drugs by mouth but did not have features of severe malaria and its complications
(11,12). Patients in the artesunate group in the Phase III studies were rescued if their
parasitaemia did not decline to below 60% of baseline parasitaemia or if they deteriorated
clinically and developed features of severe malaria, convulsions or coma within 24 h of
treatment.
Artesunate had a superior effect in all efficacy measures immediately after treatment.
In children treated with artesunate, 80/87 (92%) had a parasite density lower than 60%
of baseline, compared with 3/22 (14%) of those who received quinine (RR 0.09, 95% CI
0.04–0.19, P <0.0001). In adults, parasitaemia at 12 h was lower than 60% of baseline
in 26/27 (96%) in the artesunate group, compared with 3/8 (38%) in the quinine group
(RR 0.06, 95% CI 0.01–0.44, P <0.001). The differences were more significant at 24 h.
Artesunate and/or dihydroartemisinin were detected in plasma within 12 h in all adults
and in 84/87 of the children.

Harms
A single administration of artesunate suppositories at a dose of 10 mg/kg was well
tolerated in both children and adults. There was no significant difference in frequency of
adverse events (defined as any new symptom, worsening of any existing symptom, sign
or abnormal laboratory value) between treatment groups. Other than local reactions at
the site of the IM quinine injection in three adult patients, the few adverse events that
occurred could have been attributable to falciparum malaria or to pre-existing disease.

a8.6 Question:
Should dexamethasone be given routinely?

summary

One systematic review found no significant difference in mortality between dexamethasone
and placebo, but gastrointestinal bleeding and seizures were more common with
dexamethasone.

Benefits

One systematic review (search date: 1999, two RCTs, 143 people with severe/cerebral
malaria treated with quinine) compared dexamethasone with placebo over 48 h (13). One

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