Pediatric Malaria Medication: Antimalarials 21/11/21 20.

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Pediatric Malaria Medication

Updated: Jun 03, 2020
Author: Parang N Mehta, MD; Chief Editor: Russell W Steele, MD more...

MEDICATION

Medication Summary
Blood schizonticides are the first-line drugs for the treatment of malaria and must be started as
soon as the diagnosis is made, or even suspected, in severe disease. They act on the asexual
forms in the erythrocytes and interrupt clinical attacks. Delay in treatment of P falciparum
malaria can lead to the development or worsening of severe malaria, which has a poorer
prognosis than uncomplicated malaria. Chloroquine, quinine, quinidine, halofantrine, and
artemisinin compounds are the rapidly acting drugs that can terminate an acute malaria attack.
While chloroquine acts rapidly, resistance is widespread, and an accurate travel history should
be obtained before choosing the antimalarial drug. [13]

Malaria imported from Asia or the Americas is mostly P vivax and is chloroquine responsive.
Malaria acquired in Africa is mostly P falciparum and is chloroquine resistant; quinine is an
effective drug. P falciparum malaria incurred in Southeast Asia may be quinine and mefloquine
resistant as well; a combination of artesunate and mefloquine, or artesunate and lumefantrine, is
recommended. Time wasted in trials of a drug to which the parasite is resistant can result in a
poor outcome, including death.

P vivax and P ovale have dormant stages (hypnozoites) in the liver, and the treatment of an
episode of malaria must include eradication of these. The classic treatment is a 3-day course of
chloroquine, followed by a 14-day course of primaquine. A shorter course of 5 days of
primaquine, started with chloroquine, has been described but is associated with higher relapse
rates. However, this is adequate for gametocidal action, which prevents spread of malaria.

Tafenoquine, an antiplasmodial 8-aminoquinoline derivative, is indicated for the radical cure

(prevention of relapse) of P vivax malaria in patients aged 16 years or older who are receiving
appropriate antimalarial therapy for acute P vivax infection. [8, 9]

Intravenous (IV) artesunate is superior to quinine in the treatment of severe malaria in children
and adults. Artesunate IV was officially approved by the US Food and Drug Administration
(FDA) in May 2020 (it was previously available from the Centers for Disease Control and
Prevention [CDC] through an Investigational New Drug [IND] protocol). It is indicated for the
initial treatment of severe malaria in adults and children.

Approval was based the South East Asian Quinine Artesunate Malaria Trial (SEAQUAMAT) and
the African Quinine Artesunate Malaria Trial (AQUAMAT). These 2 studies examined a total of

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Pediatric Malaria Medication: Antimalarials 21/11/21 20.12

6,886 patients and included adults, children, and pregnant women. Artesunate IV reduced
mortality by 34.7% (P=.0002) and 22.5% (P=.002) compared with quinine in the SEAQUAMAT
and AQUAMAT studies, respectively. [14, 15]

Antimalarials

Class Summary
Blood schizonticides are the first-line drugs for the treatment of malaria.

Chloroquine (Aralen)
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This drug is effective against the erythrocytic forms of the parasite and is the drug of choice for
P vivax, P malariae, and P ovale malaria, against which it is gametocidal as well. It is not
effective against hypnozoites. It is very effective against sensitive strains of P falciparum.
However, P falciparum resistance to chloroquine is now widespread in Africa and Asia, and it
should not be depended on in severe malaria. Resistance to this drug in P vivax has also been
reported, but resistance is currently rare.

Chloroquine can be used as a suppressive prophylactic agent, with the advantage of once-
weekly dosing. It is recommended for such use only in regions where drug resistance is not
common (parts of Central America, the Caribbean, parts of the Middle East). It is available as
tablets that contain 300 mg of the base and injections that contain 40 mg base/mL.

Quinine (Qualaquin)
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Quinine is a blood schizonticidal drug and is still the drug of choice for severe and complicated
malaria in most parts of the world. It is gametocidal for P vivax and P malariae but not for P
falciparum. It is available as tablets containing 260 mg and as injections containing 300 mg/mL.
Spreading resistance among P falciparum strains to this drug make quinine less reliable in
certain parts of Asia and Africa.

Quinidine
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A stereoisomer of quinine and a blood schizonticidal drug, quinidine is as effective as quinine

against blood schizonts but has significantly more cardiac toxicity. This agent is used if quinine
is not readily available. It is available as tablets of quinidine sulphate containing 200 mg. The

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injectable preparation is not always available.

Primaquine
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Primaquine is the only drug in clinical use that destroys hypnozoites of P vivax and P ovale and
so is used for the radical cure of the relapsing malarias. It is also gametocidal against all 4
species of human plasmodia and is used to render patients noninfectious. Primaquine has a
very weak effect against erythrocytic forms of P vivax and cannot be used to terminate an acute
attack. It has no activity against erythrocytic forms of P falciparum. This drug can be
administered to patients on chemoprophylaxis after they have left the endemic area. It is not to
be used until erythrocytic forms have been destroyed by another drug.

Primaquine is an effective and fairly safe drug for chemoprophylaxis. Since it acts on the liver
forms, it need not be taken before entering a malarious area or for more than 3 days after
leaving it. This is an advantage for people making sudden or short trips.

Mefloquine
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Mefloquine is useful for the treatment of multidrug-resistant P falciparum infections. It is effective

against blood schizonts but has no activity against hypnozoites and gametocytes. Its long half-
life makes it suitable for use as a prophylactic drug, and it is the recommended drug in areas
where drug resistance is common (chiefly Africa and Asia). Not having a parenteral preparation
limits mefloquine's usefulness for severe and complicated malaria. Mefloquine may cause
adverse neuropsychiatric reactions, which may be difficult to identify in children; monitor for
symptoms, especially in nonverbal children. The drug is available as tablets containing 250 mg.

Artesunate
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Artesunate is effective against blood forms of all 4 types of human malaria parasites. Its special
usefulness is against multidrug-resistant P falciparum. It has no action against hepatic
schizonts, hypnozoites, or gametocytes. This drug is available as 50-mg tablets (outside of the
US) and IV injections containing 10 mg/mL.

Artesunate has been found to be the fastest-acting drug against blood forms of the malarial
parasite, and so the IV form is especially valuable in the management of severe and
complicated malaria.

However, resistance to this drug is spreading, particularly in Southeast Asia. Used alone,
artesunate is associated with a high recrudescence rate. It is also feared that solo use will
hasten the development of parasite resistance. Combinations of artesunate with mefloquine,
lumefantrine, and other drugs have been found to be effective against multidrug-resistant
malaria.

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Pediatric Malaria Medication: Antimalarials 21/11/21 20.12

It is indicated for initial treatment of severe malaria in adults and children. Once the patient can
tolerate oral therapy, a complete treatment course of an appropriate oral antimalarial regimen
should always follow artesunate.

Tetracycline
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Tetracycline is an antibiotic with action against blood schizonts of all species of malaria. Its
action is slow and it is used in combination with another drug, such as quinine, in areas where
resistant P falciparum is common. It is available as capsules containing 250 mg and 500 mg.

Clindamycin (Cleocin)
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This is an antibiotic that acts against P falciparum. Clindamycin has been found to be very
effective in combination with quinine, even against malaria acquired in areas where drug
resistance is common. Used in combination, it shortens the duration of fever and improves cure
rates. This is an important drug for use in children, because tetracyclines are contraindicated. It
is available as capsules containing 75 mg, 150 mg, and 300 mg and as granules that, after
reconstitution with water, contain 75 mg/5 mL.

Atovaquone and proguanil (Malarone)

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Atovaquone was recently approved in the United States for the treatment and prophylaxis of
malaria. It has significant parasiticidal activity. Proguanil and atovaquone have high failure rates
when used alone but are very successful in combination. Combining them also reduces the
selection of resistant mutants.

Malarone is available for oral use only and so can be used only for uncomplicated malaria,
against which it is very effective, even when used to fight resistant strains. It is also a useful
drug for chemoprophylaxis. It is available in adult (250 mg atovaquone and 100 mg proguanil
hydrochloride per tablet) and pediatric (62.5 mg atovaquone and 25 mg proguanil hydrochloride
per tablet) formulations.

Artemether and lumefantrine (Coartem)

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This combination is indicated for the treatment of acute, uncomplicated P falciparum malaria, the
most dangerous form of malaria. It contains a fixed ratio of 20 mg of artemether and 120 mg of
lumefantrine (1:6 parts). Both components inhibit nucleic acid and protein synthesis. Artemether
is rapidly metabolized into the active metabolite dihydroartemisinin (DHA), producing an
endoperoxide moiety. Lumefantrine may form a complex with hemin, which inhibits the formation
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of beta hematin. Artemether and lumefantrine have been shown to be effective in geographic
regions where resistance to chloroquine has been reported.

Tafenoquine (Krintafel)
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Tafenoquine is an 8-aminoquinoline derivative indicated for the radical cure (prevention of

relapse) of P vivax malaria in patients aged 16 years or older who are receiving appropriate
antimalarial therapy for acute P vivax infection. The drug is active against all stages of the P
vivax life cycle, including hypnozoites.

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