DƯỢC LÍ Goodman & Gilman's The Pharmacological Basis of Therapeutics 12th, 2010

Clinical suspicion of malaria
or history of travel to endemic area
1413
Consider
alternate diagnosis
Acquired in region
with chloroquine resistance:
Artemether-lumefantrine
(COARTEM)
or
Oral quinine sulate plus either
tetracycline or
doxycycline or clindamycin
or
Atovaquone-proguanil
(MALARONE)
or Mefloquine (LARIAM) if
above not available
Negative
Repeat thick and
thin blood smears every
12–24 h for 48–72 h
P. falciparum
or parasite species not determined
Uncomplicated malaria
Determine malaria parasite species and
likely country of aquisition of infection
Acquired in
chloroquine-sensitive
region:
Chloroquine phosphate
(ARALEN and genetrics)
or
Hydroxychloroquine
(PLAQUENIL and
generics)
Positive
Negative
P. vivax, P. ovale
P. malariae, P. knowlesi
CHLOROQUINE
PHOSPHATE
(ARALEN, generics)
or
Hydroxychloroquine
(PLAQUENIL and
generics)
plus
Primaquine for P. vivax
and P. ovale if not
G6PD deficient
Thick and thin blood smears, timely
interpretation by qualified microscopist
Positive
Assess clinical status and disease severity
Determine parasite density
P. vivax acquired in
Papua New guinea,
Indonesia or other
area with
chloroquine resistance
Quinine sulfate plus
either tetracycline or
doxycycline
or
Atovaquone-proguanil
(MALARONE)
or
Mefloquine (lariam) if
above not available
plus
Primaquine if not
G6PDdeficient
Complicated/severe malaria
or
Unable to absorb oral medication
(regardless of infecting species or
geographic region where
infection was acquired)
Intravenous artesunate* followed by
either atovaquone-proguanil (MALARONE)
or doxycycline (clindamycin
in pregnant women)
or mefloquine (LARIAM)
or
Intravenous quinidine gluconate
plus either tetracycline
or doxycycline or clindamycin
Admit to intensive care unit
Monitor cardiac function,
bood pressure, parasitemia, glucose,
hemoglobin, electrolytes
Prevent and treat complications
Consideration of exchange transfusion
for hyperparasitemia
Change to oral therapy
when oral bioavailability reliable
*investigational new drug available
through CDC Drug Service
CHAPTER 49
CHEMOTHERAPY OF MALARIA
Admit to hospital
Monitor symptoms daily
Repeat blood smears daily until negative or if
discharged prior to a negative smear, at day 7
Repeat blood smears if symptoms recur
Figure 49–4. Approach to the treatment of malaria. Atovaquone-proguanil, mefloquine, artemether-lumefantrine, tetracycline, and
doxycycline are not indicated during pregnancy. Tetracycline and doxycycline are not indicated in children <8 years of age. G6PD,
glucose- 6-phosphate dehydrogenase. (Adapted from Griffith KS, Lewis LS, Mali S, Parise ME. Treatment of malaria in the United
States: A systematic review. JAMA, 297(20):2264–77, 2007, with permission of the American Medical Association © 2007. All rights
reserved.)
Guidelines for treatment of malaria in the U.S. are
provided by the CDC and are shown in Table 49–3.
Updates should be checked on the CDC website.
Figure 49–4 presents an overview of the general strategy
for treatment of malaria in the U.S.
Treatment of Uncomplicated Malaria. Chloroquine is
the drug of choice for P. ovale, P. malariae, P. knowlesi,
and chloroquine-sensitive strains of P. vivax and P. falciparum.
For P. vivax and P. ovale infections, a 2-week
course of primaquine should be added to eradicate hypnozoites
that may remain dormant in the liver, and thus
prevent relapse. Some patients with P. vivax infection
may require more than one course of primaquine to
obtain radical cure. Primaquine must not be given to
patients with G6PD deficiency or to pregnant women.
The oral route of administration should be used if feasible.
Within 48-72 hours of initiating therapy, patients
should show marked clinical improvement (especially
clearance of fever) and a substantial decrease in parasitemia
as monitored by daily thin and thick blood
smears. Under controlled administration of treatment,
lack of such a response or failure to clear asexual forms of
the parasite from the blood by 7 days suggests the presence
of drug resistance (except for atovaquone-proguanil).