Affiliations: Projecto de Saúde de Bandim, INDEPTH Network,
Guinea-Bissau | Research Initiative of Health Services, Kolding
Hospital, Kolding, Denmark | Karolinska Institute, Stockholm, Sweden | Division of Infectious Diseases, Thoracic Medicine and
Dermatology, Mälarsjukhuset, Eskilstuna, Sweden
Abstract: Chemotherapy remains the mainstay of malaria management. Most
malaria endemic countries have national recommendations for first line therapy
(treatment of uncomplicated malaria), for second line therapy (treatment of
treatment failures) and for third line therapy (treatment of severe and
complicated malaria). Due to the increasing resistance to the commonly used
antimalarial drugs and the introduction of artemisinin containing combination
therapies as first line treatment most countries in Sub-Saharan Africa are now
recommending quinine for second line treatment. Quinine, in a dose of 10 mg/kg
three times daily for 7 days, has been shown to be an efficacious treatment for
both complicated and uncomplicated malaria. However, there is no evidence for
its efficacy as second line treatment, especially in children in whom
compliance and side effects may pose particular problems. A shorter treatment
with quinine is unlikely to be effective as in-vivo and in-vitro
studies have indicated that at least 7-day courses are needed. However,
reducing the number of doses and the total dose may be considered when quinine
is recommended as second line therapy. Single daily dosing, though possibly
effective, increases the risk of side effects, whereas twice daily dosing with
10 mg/kg for 7 days may be a treatment option. Using quinine as both second and
third line therapy coupled with a possible poor adherence to the treatment
schedule increases the risk of quinine resistance developing. In order to have
an effective second line treatment and to decrease the risk of resistance to
the third line treatment an alternative to quinine for second line therapy
would be desirable. There is at present no obvious candidate but the
re-emergence of chloroquine sensitivity in Malawi raises the possibility that
chloroquine could be reintroduced.
