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malaria treatment medications WHO guidelines 2025
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"malaria"[MeSH Terms] AND "antimalarial drugs"[MeSH Terms]
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Medicines for Malaria
Treatment depends on the species of Plasmodium, disease severity, and patient-specific factors (pregnancy, G6PD status, region of infection). Below is a structured guide.
1. P. vivax / P. ovale (Uncomplicated)
| Drug | Dose | Purpose |
|---|---|---|
| Chloroquine phosphate | 25 mg/kg total over 3 days (10 mg/kg day 1, 10 mg/kg day 2, 5 mg/kg day 3) | Kills blood-stage parasites |
| Primaquine | 0.25 mg/kg/day x 14 days | Eradicates liver hypnozoites (prevents relapse) |
| Tafenoquine (alternative) | 300 mg single dose | Anti-relapse (alternative to primaquine) |
Critical warning: Primaquine and tafenoquine are contraindicated in G6PD-deficient patients (causes hemolysis), pregnant women, and infants. Always test G6PD before giving these drugs.
For P. vivax from Papua New Guinea or Indonesia (chloroquine-resistant): use Atovaquone-proguanil, Quinine + doxycycline, or Mefloquine instead.
2. P. falciparum (Uncomplicated)
Chloroquine-resistant strains (most of the world):
| Regimen | Dose |
|---|---|
| Artemether-lumefantrine (Coartem) (preferred) | 4 tablets twice daily x 3 days |
| Atovaquone-proguanil (Malarone) | 4 tablets once daily x 3 days |
| Quinine + Doxycycline | Quinine 650 mg TID x 3-7 days + Doxycycline 100 mg BID x 7 days |
| Quinine + Clindamycin | Quinine 650 mg TID x 3-7 days + Clindamycin 600 mg BID x 7 days |
| Mefloquine | 750 mg then 500 mg after 6-8 hours (or 1250 mg single dose) |
- In India (non-NE states): ACT = Artesunate (3 days) + Sulphadoxine-pyrimethamine (1 day) + single dose Primaquine 0.75 mg/kg on day 2.
- In NE India (SP resistance reported): use Artemether + Lumefantrine (age-specific dosing).
- Also add a single dose of primaquine (gametocidal) to reduce transmission.
Chloroquine-sensitive strains (Central America west of Panama Canal, Haiti, Dominican Republic):
- Chloroquine phosphate alone (same dose as above)
3. P. malariae
- Chloroquine alone (no primaquine needed - no hypnozoite stage)
4. Severe / Complicated Malaria (any species, or unable to take oral drugs)
| Drug | Dose | Route |
|---|---|---|
| IV Artesunate (first choice) | 2.4 mg/kg at 0, 12, 24 hr then daily | Intravenous |
| IV Quinine dihydrochloride | 20 mg/kg loading over 4 hr, then 10 mg/kg every 8 hr | Intravenous |
| IM Artemether | 3.2 mg/kg IM, then 1.6 mg/kg/day | Intramuscular |
Once the patient can tolerate oral drugs, switch to a full oral course (doxycycline, clindamycin, or another appropriate regimen). Cardiac monitoring is mandatory during IV quinine.
5. Malaria in Pregnancy
| Trimester | P. falciparum | P. vivax |
|---|---|---|
| 1st trimester | Quinine + Clindamycin (ACT avoided) | Chloroquine (safe) |
| 2nd & 3rd trimester | ACT (Artemether-lumefantrine or AS+SP) | Chloroquine |
- Primaquine is contraindicated throughout pregnancy.
- Atovaquone-proguanil, mefloquine, doxycycline, and tetracycline are generally avoided in pregnancy.
6. Mixed Infections
Treat as P. falciparum with the appropriate ACT regimen.
Key Drug Summary Table
| Drug Class | Drugs | Use |
|---|---|---|
| Artemisinin combination therapy (ACT) | Artemether-lumefantrine, Artesunate-SP, Artesunate-amodiaquine | Uncomplicated falciparum (1st line) |
| Quinoline | Chloroquine, Quinine, Mefloquine | Vivax; resistant falciparum |
| Antifolate combo | Atovaquone-proguanil | Resistant falciparum |
| 8-aminoquinoline | Primaquine, Tafenoquine | Anti-relapse for vivax/ovale |
| Antibiotic add-on | Doxycycline, Clindamycin, Tetracycline | Partner drug with quinine |
Sources:
- Park's Textbook of Preventive and Social Medicine, pp. 306-307
- Goldman-Cecil Medicine, Table 316-1
- Goodman & Gilman's Pharmacological Basis of Therapeutics, pp. 1322-1323
- WHO Guidelines for Malaria (August 2025)
- CDC Malaria Treatment Tables
Note: Always confirm the species by blood film/RDT before treatment. Treatment protocols vary by region due to resistance patterns. For life-threatening severe malaria, start IV artesunate immediately without waiting for full diagnostic workup.
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