| I. Artemisinin combination therapy | |||
| Drug | Formulations available | Body weight (kg) | Dose* |
| Artemether-lumefantrine¶Δ | Available as tablets containing 20 + 120 mg or 40 + 240 mg of artemether and lumefantrine, respectively; an orally disintegrating flavored tablet is available in some areas | Dose administered orally twice daily for three days: | |
| 5 to 15 | 20 + 120 mg | ||
| 15 to <25 | 40 + 240 mg | ||
| 25 to <35 | 60 + 360 mg | ||
| ≥35 | 80 + 480 mg | ||
| Artesunate-amodiaquine | Available as tablets containing 25 + 67.5 mg, 50 + 135 mg, or 100 + 270 mg of artesunate and amodiaquine, respectively | Dose administered orally once daily for three days: | |
| 4.5 to 9 | 25 + 67.5 mg | ||
| 9 to <18 | 50 + 135 mg | ||
| 18 to <36 | 100 + 270 mg | ||
| ≥36 | 200 + 540 mg | ||
| Dihydroartemisinin-piperaquine◊ | Available as tablets containing 20 + 160 mg or 40 + 320 mg of dihydroartemisinin and piperaquine, respectively | Dose administered orally once daily for three days: | |
| 5 to 8 | 20 +160 mg | ||
| 8 to <11 | 30 + 240 mg | ||
| 11 to <17 | 40 + 320 mg | ||
| 17 to <25 | 60 + 480 mg | ||
| 25 to <36 | 80 + 640 mg | ||
| 36 to <60 | 120 + 960 mg | ||
| 60 to <80 | 160 + 1280 mg | ||
| ≥80 | 200 + 1600 mg | ||
| Artesunate-mefloquine§ | Available as tablets containing 25 + 55 mg or 100 + 220 mg of artesunate and mefloquine hydrochloride, respectively | Dose administered orally once daily for three days: | |
| 5 to 9 | 25 + 55 mg | ||
| 9 to <18 | 50 + 110 mg | ||
| 18 to <30 | 100 + 220 mg | ||
| ≥30 | 200 + 440 mg | ||
| II. Alternative regimens (if ACT is not available)¥ | |||
| Drug regimen‡ | Adults | Children | |
| 200 mg orally once daily for three days | Available as 50 mg tablets | |
| Dose administered orally once daily for three days: | |||
| 4.5 to <9 kg: 25 mg | |||
| 9 to <18 kg: 50 mg | |||
| 18 to <36 kg: 100 mg | |||
| ≥36 kg: 200 mg | |||
| plus one of the following: | |||
| 100 mg orally twice daily for seven days | Children ≥8 years: 2.2 mg/kg (maximum 100 mg) orally every 12 hours for seven days | |
| 20 mg base/kg/day (up to 1.8 grams) orally divided three times daily for seven days | 6.7 mg base/kg orally (maximum 600 mg) orally every 8 hours for seven days | |
| 542 mg base ( = 650 mg salt)¶¶ orally three times daily for three or seven daysΔΔ | 8.3 mg base/kg ( = 10 mg salt/kg) orally three times daily for three or seven daysΔΔ | |
| plus one of the following: | |||
| Dosing as above | Dosing as above | |
| Dosing as above | Dosing as above | |
Adult tab = 250 mg atovaquone/100 mg proguanil Pediatric tab = 62.5 mg atovaquone/25 mg proguanil | 4 adult tabs orally once daily for three days | 5 to 8 kg: 2 pediatric tabs orally once daily for three days | |
| 9 to 10 kg: 3 pediatric tabs orally once daily for three days | |||
| 11 to 20 kg: 1 adult tab orally once daily for three days | |||
| 21 to 30 kg: 2 adult tabs orally once daily for three days | |||
| 31 to 40 kg: 3 adult tabs orally once daily for three days | |||
| >40 kg: 4 adult tabs orally once daily for three days | |||
| 684 mg base ( = 750 mg salt) orally as initial dose, followed by 456 mg base ( = 500 mg salt) orally given 6 to 12 hours after initial dose. Total dose = 1250 mg salt. | 13.7 mg base/kg ( = 15 mg salt/kg maximum 750 mg) orally as initial dose, followed by 9.1 mg base/kg ( = 10 mg salt/kg) orally given 6 to 12 hours after initial dose. Total dose = 25 mg salt/kg. | |
An oral regimen should be administered for completion of treatment for severe malaria, following administration of parenteral therapy (for at least 24 hours and until oral medication can be tolerated). (Refer to the UpToDate table summarizing parenteral regimens for treatment for severe malaria.)
The dosing regimens listed in this table are generally consistent with the World Health Organization 2015 guidelines (3rd edition) for the treatment of malaria and the United States Centers for Disease Control and Prevention guidelines for the treatment of uncomplicated malaria in the United States (as revised July 2013) and may differ from dosing recommended in approved product information. Product availability varies by locality.ACT: artemisinin combination therapy.
* In general, the course of ACT is administered for three days. In areas of artemisinin resistance, a six-day course of treatment is warranted.
¶ Take after a full meal or whole milk. If patient vomits within 30 minutes of taking a dose, then they should repeat the dose. Ideally, the first 2 doses should be taken 8 hours apart. Late recrudescence rates of ~5% have been reported in nonimmune males, treated with 6 doses of artermether-lumefrantrine[5]; in such cases, close follow-up is warranted and if retreatment is needed, an alternative regimen should be used.
Δ Artemether-lumefantrine is the only ACT available in the United States.
◊ Piperaquine prolongs the QT interval by approximately the same amount as chloroquine but by less than quinine. Dihydroartemisinin-piperaquine should not be used in patients with congenital QT prolongation or who are on medications that prolong the QT interval. Dihydroartemisinin-piperaquine may be taken with food but should not be taken with a high-fat meal.
§ Regimens containing mefloquine should be avoided in patients who presented with altered consciousness, since there is an increased incidence of neuropsychiatric toxic effects associated with mefloquine in the setting of cerebral malaria. In addition, treatment with mefloquine is not recommended in persons who have acquired infections from Southeast Asia due to drug resistance. Mefloquine hydrochloride (55 mg) is equivalent to mefloquine base (50 mg); mefloquine hydrochloride (220 mg) is equivalent to mefloquine base (200 mg).
¥ The alternative regimens summarized in the table are for completion of treatment for severe malaria acquired in areas with chloroquine-resistant malaria. For completion of therapy for severe malaria acquired in areas with chloroquine-sensitive malaria (Haiti, the Dominican Republic, most regions of the Mid East, and Central America west of the Panama Canal), chloroquine may be administered. Dosing of chloroquine for adults consists of 600 mg base ( = 1000 mg salt) orally immediately, followed by 300 mg base ( = 500 mg salt) orally at 6, 24, and 48 hours; total dose: 1500 mg base ( = 2500 mg salt). Dosing of chloroquine for children consists of 10 mg base/kg orally immediately, followed by 5 mg base/kg orally at 6, 24, and 48 hours; total dose: 25 mg base/kg. Maximum total dose: 1500 mg base ( = 2500 mg salt).
‡ Regimens summarized include those generally available in areas where malaria is endemic. Atovaquone-proguanil is an acceptable alternative in regions where available. Adult dosing consists of 4 adult tabs (250 mg atovaquone/100 mg proguanil) orally once daily for three days. Pediatric dosing is as follows: 5 to 8 kg: 2 pediatric tabs (62.5 mg atovaquone/25 mg proguanil) orally once daily for three days; 9 to 10 kg: 3 pediatric tabs orally once daily for three days; 11 to 20 kg: 1 adult tab orally once daily for three days; 21 to 30 kg: 2 adult tabs orally once daily for three days; 31 to 40 kg: 3 adult tabs orally once daily for three days; >40 kg: 4 adult tabs orally once daily for three days.
† Oral artesunate is not available in the United States or Canada.
** Doxycycline is preferred over other tetracyclines because it does not accumulate in renal failure and has a longer half-life. Tetracycline may be used as an alternative (adult dosing: 250 mg orally four times daily for seven days; pediatric dosing: 6.25 mg/kg orally every 6 hours for seven days). Tetracycline antibiotics may cause permanent tooth discoloration for children <8 years if used repeatedly. However, doxycycline binds less readily to calcium than other tetracyclines and may be used for ≤21 days in children of all ages.[1] Clindamycin is preferred to tetracyclines in pregnancy.
¶¶ United States-manufactured quinine sulfate capsule is only available in a 324 mg (salt) strength; therefore, two capsules should be sufficient for adult dosing. Pediatric dosing may be difficult due to unavailability of noncapsule forms of quinine in the United States.
ΔΔ For infections acquired in Southeast Asia, oral treatment consists of quinine (seven days) plus doxycycline or clindamycin (seven days). For infections acquired outside Southeast Asia, oral treatment consists of quinine (three days) plus doxycycline, tetracycline, or clindamycin (seven days).
◊◊ Atovaquone-proguanil has been associated with treatment failure and should be used only if the preceding regimens are not available. The drug should be taken with food or whole milk. If the patient vomits within 30 minutes of taking a dose, then dose should be repeated. It is also acceptable to take one-half of the dose twice daily.
§§ Treatment with mefloquine is not recommended in individuals who have acquired infections from Southeast Asia due to drug resistance. Mefloquine is associated with adverse psychiatric and neurologic events and should be used only if the preceding agents are not available. Mefloquine is not recommended for children <15 kg.