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
