Malaria Drugs Flashcards
Criteria needed for defining Uncomplicated Malaria
CNS - Normal mental state
Ambulation - Can walk
Cardinal signs - No jaundice
Vitals - Normal
GU - Adequate output
Ability to tolerate oral meds - Not vomiting
Abn bleeding - none
Lab values - Within uncomplicated range
Criteria needed for defining Severe Malaria
CNS - Lower GCS & Convulsions [>2 in 24hr]
Ambulation - Severe weakness/ Prostrations
Cardinal signs - Jaundiced
Vitals - LOW BP [<80]; Resp. distress [30+ RR; acidotic breathing etc.];
Shock
GU - Macroscopic haematuria / Anuria/ red brown urine
Ability to tolerate oral meds - Usually vomiting
Abn bleeding - they have retinal haemorrhages, haematemesis, melaena
Lab values - deranged [parasite density >4%; Hb < 5; Met. acidosis; etc.]
Danger signs of severe disease
- Unable to drink/feed
- repeated vomiting
- Hx of convulsions
- Neurological change
- Abnormal breathing effort
- Persistent vomiting and diarrhoea
- Jaundice
- Bleeding
- Dark urine
- delayed capillary refill
- intense pallor
- hyperpyrexia
High risk patients (admit and monitor)
- Pregnancy and post-partum
- infants and young
- elderly > 65 y/o
- Immunocompromised [HIV]
- Splenectomized
- Co-morbidities
benefits and risks of quinine plus doxycycline [/clindamycin] versus artemether-lumefantrine
benefits and risks of quinine plus doxycycline [/clindamycin] versus artemether-lumefantrine
Artemether-Lumefantrine
- Rapid schizonticidal activity
- Effective again MDR P falciparum
- Rapid clinical & parasitological response
- Favourable safety profile
- Decreases malaria transmission
Quinine
- poorly tolerated- affects adherence
- limited effect on malaria transmission
- Give quinine + doxy/ clindamycin if: A-L not available or contraindicated
Or in Infants <5, Pregnancy in 1st trimester
Why is combination therapy now recommened
Monotherapy increases risk of resistance
Benefits and risks of IV Artesunate vs IV quinine for the first line Rx of severe falciparum malaria
Advantages of IV (IM) artesunate vs. quinine
1.Reduction in mortality (39%)
2. More rapid parasite clearance
3. Simple to administer
4. Simple dose regimen
5. Better safety profile
6. No dose adjustments required in renal and hepatic impairment
Disadvantages of Quinine:
Benefits and risks of IV Artesunate vs IV quinine for the first line Rx of severe falciparum malaria
Advantages of IV (IM) artesunate vs. quinine
1.Reduction in mortality
2. More rapid parasite clearance
3. Simple to administer
4. Simple dose regimen
5. Better safety profile
6. No dose adjustments required in renal and hepatic impairment
Disadvantages of Quinine:
Benefits and risks of IV Artesunate vs IV quinine for the first line Rx of severe falciparum malaria
Advantages of IV (IM) artesunate vs. quinine
1.Reduction in mortality
2. More rapid parasite clearance
3. Simple to administer
4. Simple dose regimen
5. Better safety profile
6. No dose adjustments required in renal and hepatic impairment
Disadvantages of Quinine:- {hehe this looks like pipi
-Needs rate-controlled infusion of 8 hrs
-Needs cardiac monitoring
-Needs dose adjustment in renal failure
-Adjust dose in obesity to ideal body weight
-Narrow therapeutic window
-Hypoglycaemia (esp pregnancy & children)
-Cinchonism (hearing loss, tinnitus, headache, visual disturbances)
In severe malaria, how should treatment be completed once they can tolerate oral medications again?
- at least 3 IV doses [@ 0, 12, 24 hrs] should be given in severe malaria before switching to oral therapy
- Patients can then complete a full course [six doses] of artemether-lumefantrine
Should the dosing of IV artesunate and/or IV quinine be adjusted in pts. with renal failure and if so, how?
No dose adjustment is needed for renal or hepatic impairment patients in artesunate.
In IV quinine, you decreased the maintenance dose after day 3 (quinine is renally eliminated)
Should the dosing of IV artesunate and/or IV quinine be adjusted in pts. with renal failure and if so, how?
No dose adjustment is needed for renal or hepatic impairment patients in artesunate.
In IV quinine, you decreased the maintenance dose after day 3 (quinine is renally eliminated)
Should the dosing of IV artesunate and/or IV quinine be adjusted in pts. with renal failure and if so, how?
No dose adjustment is needed for renal or hepatic impairment patients in artesunate.
In IV quinine, you decreased the maintenance dose after day 3 (quinine is renally eliminated)
What monitoring would you recommend for a patient a) with severe malaria and b) being administered IV artesunate and c) being administered IV quinine?
SEVERE MALARIA: Assess organ function: CNS, jaundice, renal, cardiac, respiratory, bleeding, anemia 🡺 specific management
Bloods: HB; U, E & Cr; Blood glucose; ABG – acidotic; Lactate; Bilirubin; Consider blood culture
Vitals every 4hrs w/ glucose
Daily smears
IV Artesunate: Artesunate has excellent safety and tolerability. Delayed Haemolysis is common, monitor Hb and treat. Monitor for other rare haematological disorders, elevated AST
IV Quinine: Parenteral quinine can cause QTc prolongation and should be administered with electrocardiographic monitoring; QT interval should be monitored hourly, and the infusion should be stopped if the corrected QT interval becomes prolonged by more than 50 percent of the baseline value. Quinine can act as a pancreatic secretagogue, leading to hyperinsulinemic hypoglycemia. Other toxic effects include tinnitus, reversible hearing loss, nausea, vomiting, dizziness, and visual disturbances.
Explain the rationale behind the use of an IV quinine loading dose in patients with severe malaria
- Severe sepsis decreases Vd (volume of distr.)
- Quinine binds to acute phase reactant proteins, which increase with disease severity
- To achieve therapeutic concentrations as quickly & safely as possible
recommended therapy for uncomplicated non-falciparum malaria
ie. Plasmodium ovale, P. vivax, P. malariae and P. knowlesi.
1- Artemesinin-based combo Tx [first line]
Consists of Artemether (acts against gametocytes and has rapid schizonticidal activity)
& Lumefantrine (rapid schizonticidal activity)
Advantages = effective against MDR strains, Artemisinin has rapid clinical and parasitological response with favorable safety profile and decreased malaria transmission
Directions = take all 6 doses over 3 days, take with food or milk containing fat
2 - Fluids
3 - Paracetamol
Response expected in 24-48 hrs, pt. to return if fever still on D3 or cont. vomiting or deterioration
Contra-indications:
recommended therapy for uncomplicated non-falciparum malaria
ie. Plasmodium ovale, P. vivax, P. malariae and P. knowlesi.
1- Artemesinin-based combo Tx [first line]
Consists of Artemether (acts against gametocytes and has rapid schizonticidal activity)
& Lumefantrine (rapid schizonticidal activity)
Advantages = effective against MDR strains, Artemisinin has rapid clinical and parasitological response with favorable safety profile and decreased malaria transmission
Directions = take all 6 doses over 3 days, take with food or milk containing fat
2 - Fluids
3 - Paracetamol
Response expected in 24-48 hrs, pt. to return if fever still on D3 or cont. vomiting or deterioration
Contra-indications: Allergic; <5kg; Pregnant; Severe malaria
Malaria Prevention
Drug Prophylaxis:
- Doxycycline
- Mefloquine
- Atovaquone-Proguanil
Non-drug measures
Remain indoors
Wear long-sleeved clothing.
Screen doorways and windows
Apply a DEET-containing repellent
Use mosquito mats & coils
Use insecticide-treated bed nets
Spray aerosol insecticide
Use ceiling fans /air conditioner
Treatment uncomplicated malaria caused by P.falci, P. malariae or P. knowlesi
Aremether-lumefantrine
or Oral quinine plus doxycycline/clindamycin
Treatment P.ovale, P. vivax
Artemether-lumefantrine followed by primaquine
treatment severe malaria (usually P. falci)
IV artesunate or IV quinine if artesunate unavailable
once able to tolerate oral treatment:
artemether-lumefantrine or quinine plus doxycycline/clindamycin
