Malaria treatment. Dr abdulrahman al shaikh.

Introduction million patients died because of malaria every year. Most deaths due to Plasmodium Falciparum and in between children. In recent years malaria increased and treatment failure also increased because of resistance.

General principle in treatment. Supportive measures plus specific anti malaria treatment. Patients with P- vivax, P-ovale, or P- malariae infection can be treated as out patients. P- falciparum should be started immediately and should be admitted for observation for complication. Most patients treated by oral medication except in severe cases need IV drugs. Severe cases should be treated in ICU for observation, fluid resuscitation and electrolytes monitoring. Glucose for hypoglycemia, paracetamol for fever and benzodiazepine for seizures.

Anti malarial drugs. Quinoline derivatives. Antifolates. Artemisinin derivatives. Antimicrobial.

Quinoline derivatives. Chloroquine, quinine, guinidine, amodiaquine, mefloquine, halofantrine, and primaquine. It inhibit heme polymerase activity resulting in accumulation of the free heme which is toxic to the parasites. Chloroquine also inhibit the release and action of tumor necrosis factor – alpha. The first six drugs kill the parasite in the intra erythrocyte phase and primaquine kill the parasite both intra erythrocyte and intra hepatic phases.

Antifolates. Pyrimethamine, sulfonamide, dapsone and proguanil ( fansidar is combination of Pyrimethamine and sulfadoxine). It kill intrahepatic form but not hypnozoites.

Artemisinin derivatives. Artemisinin, artemether and artesunate. It bind iron in the malarial pigment to produce free radicals that damage parasite protein.

Antimicrobials. Clindamycin, atovaquone and tetracycline. It act synergistically with Quinoline derivatives to kill blood schizonts.

Chloroquine resistance. No resistance of P- ovale or P- malariae. Reported cases of P- vivax resistance to Chloroquine in Africa. Plasmodium falciparum chloroquine resistance increased and wide spread all over the world. Most require alternative treatments.

Recommendation for therapy. Recommendation of treatments.

Severe Falciparum Malaria. A parasitemia > 5%. Altered consciousness. Oliguria. Jaundice. Severe normocytic anemia. Hypoglycemia. Organ failure.

Quinine based regimen. Quinidine gluconate IV 10 mg/ kg loading dose in normal saline maximum 600 mg over one tow hours then continuous infusion 0.02 mg / kg per minute. Intravenous quinine dihydrochloride 20 mg /kg 2-4 hours 3 times per day but no more than 1800 mg/day. Patients who receive mefloquine or any quinine derivatives within the previous 12 hours should not receive loading dose of quinidine or quinine.