Failures following initial treatment for uncomplicated malaria: Quinine as second line therapy

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.

Keywords

Malaria - quinine - treatment failure