How to give artem ds in malaria
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Artemisinin Derivatives (Artem DS) in Malaria - Dosing Guide
"Artem DS" refers to artemisinin-based derivatives - primarily artesunate, artemether, and their combination partners used as Artemisinin-Based Combination Therapies (ACTs).
1. Severe / Complicated Malaria (Parenteral Artesunate - FIRST LINE)
Artesunate is the drug of choice for severe falciparum malaria. Large trials in Southeast Asia showed a 35% lower mortality compared to quinine, and a 22.5% reduction in Africa.
IV Artesunate (Adults, weight ≥20 kg)
| Timing | Dose |
|---|---|
| 0 h (loading dose) | 2.4 mg/kg IV (Harrison's) OR 3 mg/kg IV (Washington Manual) |
| 12 h | 2.4 mg/kg IV |
| 24 h | 2.4 mg/kg IV |
| Then daily | 2.4 mg/kg IV/day until oral therapy possible |
Children <20 kg: Use 3 mg/kg per dose (Harrison's, 2025)
- Washington Manual gives an alternative loading dose scheme: 3 mg/kg at 0 h, then 3 mg/kg at 12 h and 24 h, then 3 mg/kg once daily for 3 days.
- After IV stabilization: Switch to oral ACT (artemether-lumefantrine, atovaquone-proguanil, or quinine + doxycycline/clindamycin).
IM Artemether (if IV artesunate unavailable)
- 3.2 mg/kg IM stat, then 1.6 mg/kg IM once daily
- Note: Oil-based, erratically absorbed - does NOT confer same survival benefit as artesunate IV.
Quinine IV (last resort, if artesunate unavailable)
- 20 mg salt/kg infused over 4 h, then 10 mg salt/kg over 2-8 h every 8 h.
2. Uncomplicated Falciparum Malaria (Oral ACTs - FIRST LINE)
A. Artemether-Lumefantrine (Coartem) - Standard adult regimen
Each tablet contains artemether 20 mg + lumefantrine 120 mg.
| Time | Dose |
|---|---|
| 0 h | 4 tablets PO |
| 8 h | 4 tablets PO |
| Day 2 (q12h) | 4 tablets PO x2 |
| Day 3 (q12h) | 4 tablets PO x2 |
Total: 6 doses over 3 days - Washington Manual of Medical Therapeutics
Give with food (fatty meal increases absorption). First-line for uncomplicated falciparum in chloroquine-resistant areas. This is the only artemisinin-based combination therapy approved in the United States.
B. Artesunate-Sulfadoxine-Pyrimethamine (ACT-SP) - India National Program
Per Park's Textbook (India NVBDCP guidelines):
| Drug | Dose | Duration |
|---|---|---|
| Artesunate (50 mg tabs) | 4 mg/kg/day | Days 1, 2, 3 |
| Sulfadoxine-Pyrimethamine | 25 mg/kg sulfadoxine + 1.25 mg/kg pyrimethamine | Day 1 only |
| Primaquine (large tabs) | 0.75 mg/kg | Day 2 only (gametocidal) |
- Used in most Indian states (except North-Eastern states).
- North-Eastern states: Use Artemether-Lumefantrine instead (due to SP resistance).
C. Other Oral ACT Options
- Artesunate-amodiaquine - widely used in Africa
- Dihydroartemisinin-piperaquine (DHA-PPQ) - once daily x3 days
- Atovaquone-proguanil - 4 tabs once daily x3 days (alternative)
3. Rectal Artesunate (Pre-referral, Community Level)
For severely ill children in rural areas who cannot take oral medications:
- Rectal artesunate acts as a pre-referral bridge to reduce mortality before reaching a hospital.
- Shown to decrease mortality in severely ill children without immediate access to parenteral treatment. - Harrison's Principles of Internal Medicine, 22E (2025)
4. Uncomplicated Vivax / Ovale Malaria
- Artemisinins are generally not first-line for vivax; chloroquine remains preferred in sensitive areas.
- If using ACT for vivax, always add primaquine (0.25 mg base/kg/day x 14 days) after ruling out G6PD deficiency to prevent relapse.
5. Special Situations
| Situation | Recommendation |
|---|---|
| Artemisinin-resistant area (confirmed) | Give both IV artesunate + quinine together in full doses |
| Pregnancy | Artemisinins are used in 2nd/3rd trimesters for severe malaria; avoid in 1st trimester if alternatives available |
| Gametocidal action | Add single-dose primaquine 0.25 mg base/kg (even in G6PD deficiency, as single-dose is safe) to prevent transmission in low-transmission areas |
| Loading dose / prior quinine | Do NOT give quinine loading dose if quinine given within previous 24 h |
Key Points Summary
- Severe malaria: IV artesunate is preferred over quinine (lower mortality, better tolerated)
- Uncomplicated falciparum: Artemether-lumefantrine OR artesunate + partner drug for 3 days
- Children <20 kg: Higher weight-based dose (3 mg/kg) for IV artesunate
- Oral switch: As soon as patient can tolerate oral fluids, switch from parenteral to oral ACT
- Adverse effects of artesunate: thrombocytopenia, hemolytic anemia, elevated liver enzymes, hyperbilirubinemia - Lippincott Pharmacology
Sources: Harrison's Principles of Internal Medicine 22E (2025), Washington Manual of Medical Therapeutics, Park's Textbook of Preventive & Social Medicine, Goodman & Gilman's Pharmacological Basis of Therapeutics, Lippincott Illustrated Reviews: Pharmacology
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