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Guidelines for the treatment of malaria – 2 edition

a9.7 Question:
Is 14 days of primaquine superior to 5 days of primaquine for preventing relapses
of P. vivax?

Background
Primaquine is the most widely used drug for the treatment of the liver stage of P. vivax.
Treatment regimes vary between countries.

GraDE approach
The evidence included in this table is based on the Cochrane review titled “Primaquine
for preventing relapses in people with Plasmodium vivax malaria” published in 2007 (99).
For the purposes of these guidelines the outcome measure has been converted from odds
ratio (used in the review) to risk ratio for consistency.
1. Is 14 days of primaquine superior to five days of primaquine in preventing relapses of
P. vivax? (See GRADE Table A9.7.1)

When assessing this evidence the WHO GRADE panel considered the following factors
to be important:
• ACTs do not have a substantial effect on the liver stage of P. vivax so radical cure
requires primaquine.

Other considerations

In addition to the presented direct comparison, the Cochrane review reports indirect
evidence of the superiority of the 14-day regimen. No difference has been shown between
the five-day regimen and chloroquine alone (3 trials, 2104 participants; OR 1.04, 95% CI
0.64–1.69), while the 14-day regimen is significantly better at reducing relapses (6 trials,
1072 participants; OR 0.24, 95% CI 0.12–0.45).

Decision
The WHO GRADE panel makes a strong recommendation that for the radical treatment
of P. vivax primaquine be given for 14 days.

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