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Exam 5 - Therapeutics > Management of Malaria > Flashcards

Management of Malaria Flashcards

1
Q

Individuals most vulnerable to malaria

A

-Young children
-Pregnant women (Parasite can sequester into placenta)
-Travelers/migrants coming from areas with little of no malaria transmission

**People who don’t have immunity

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2
Q

Antimalarial resistance

A

-Chloroquine-resistant P. falciparum is widespread
-Artemisinin-resistance arising (still 1st line for majority of the world though!)

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3
Q

Malaria transmission, distribution and incidence of vector-born infections are impacted by ___ & ____

A

Extreme weather events (floods)
Increasing temperatures

*Changing climate has the potential to increase the distribution of malaria

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4
Q

Malaria lifecycle

A
  1. Parasite enters bloodstream
  2. Goes to liver
  3. Forms schizont
  4. Goes into RBC
  5. When RBC lyses, parasites are released & pt gets fever/chills
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5
Q

Plasmodium spp that cause infections in humans

A
  1. P. falciparum
  2. P. malariae
  3. P. knowlesi
  4. P. vivax
  5. P. ovale
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6
Q

Which plasmodium spp have dormant liver stage

A

P. vivax
P. ovale
**Give separate med to tx these!

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7
Q

Malaria prevention: vector control

A

-Prevent spread of malaria
-Aimed to kill mosquito reservoir by using
1. Indoor residual spraying (coats walls & surfaces in the house; requires > 80% of houses sprayed)

  1. DDT (no longer recommended due to environmental concerns and resistance)
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8
Q

Mosquito avoidance measures
-Malaria is primarily transmitted at ____ & ____
-Measures to reduce transmission at residence: __

A

dawn and dusk

-Sleep under mosquito nets
-Stay in enclosed, air-conditioned room
-Use mosquito coils in living spaces
-Use effective mosquito repellent (apply after sunscreen)
-Permethrin treated clothing & gear

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9
Q

Malaria vaccines available

A

RTS,S
R21

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10
Q

Indication for malaria vaccine

A

-Children living in regions with moderate - high P. falciparum transmission

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11
Q

Dosing schedule for malaria vaccine

A

4 doses of vaccine starting ~5 months of age

*can consider a 5th dose in areas of highly seasonal transmission

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12
Q

Malaria risk assessment

A

-Travel destination
-Altitude of destination (200,000 m above sea level will have less risk of malaria)
-Time of travel (during rabies season)
-Type of living accomodation
-Length of stay

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13
Q

What book do you lookin for risk assessment based on travel destination?

A

YELLOW book

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14
Q

Chemoprophylaxis (depends on region you are traveling to)
-ALL MALARIA ENDEMIC REGIONS

A
  1. Atovaquone/proguanil
  2. Doxycycline
  3. Tafenoquine
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15
Q

Chemoprophylaxis
-Regions with chloroquine-sensitive malaria

A

-Chloroquine
-Hydroxychloroquine

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16
Q

Chemoprophylaxis
-Regions primarily with P. vivax

A

Primaquine

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17
Q

Chemoprophylaxis
-Regions with mefloquine-sensitive malaria

A

Mefloquine

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18
Q

Atovaquone/Proguanil (Malarone) duration of tx

A

1-2 days before departure
continue for 7 days after leaving endemic area

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19
Q

Malarone counseling points

A

Take with food/milk

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20
Q

Malarone pros/cons

A

Pros
-Good for last minute travel/shorter trips
-Well tolerated
-Can use in ALL malaria endemic countries

Cons
-$$

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21
Q

Reasons to avoid malarone

A

-CrCl < 30 ml/min (C/I)
-Pregnancy
-Women breastfeeding infants < 5 kg
-Children < 5 kg

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22
Q

Chloroquine duration

A

Begin 1-2 weeks before departure
Continue for 4 weeks after leaving malaria endemic area

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23
Q

Chloroquine counseling

A

-Blurred vision
-Dizziness/HA
-GI disturbance
-Insomnia
-Itching

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24
Q

Chloroquine pros/cons

A

Pros
-Only need to take once weekly
-Can be used in all trimesters of pregnancy

Cons
-Need to take 4 weeks after returning
-Not good choice for last minute travel
-MUST ensure traveling to region with chloroquine sensitive malaria

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25
Hydroxychloroquine duration
Begin 1-2 weeks before departure Continue 4 weeks after leaving malaria endemic area
26
Hydroxychloroquine counseling points
-Blurred vision -Dizziness/HA -GI disturbance -Insomnia -Itching **Same as chloroquine
27
Hydroxychloroquine pros/cons
Pros -Only need to take once weekly -Can be used in all trimesters of pregnancy Cons -Need to take 4 weeks after returning -Not good choice for last minute travel -MUST ensure traveling to region with chloroquine sensitive malaria **Same as chloroquine
28
Doxycycline duration
Begin 1-2 days before departure Continue 4 weeks after leaving malaria endemic region
29
Doxycycline counseling points
1. Wear sunscreen 2. Separate ingestion from positive cations (Calcium carbonate & milk) 3. SE: diarrhea, abdominal pain, photosensitivity, vulvovaginal candidiasis (yeast infection)
30
Doxycycline pros/cons
Pros: -good for last minute travel -Can prevent some additional infections -Least expensive -Can be used in all malaria-endemic regions Cons: -Must take for 4 weeks after returning -Once daily med
31
Reasons to avoid doxycycline
-Women who are pregnant -Children < 8 y/o -Allergy to tetracyclines -Women prone to getting vaginal yeast infection
32
Mefloquine duration
Begin at least 2 weeks before departure & continue 4 weeks after leaving malaria endemic area
33
Mefloquine counseling points
-Has been associated with psychosis/seizure -Side effects: abnormal dreams, anxiety, depression, dizziness, visual disturbances
34
Mefloquine pros/cons
Pros -Once weekly -Can be used in all trimesters of pregnancy Cons -Must take for 4 weeks after returning -Not good for last minute travel
35
Reasons to avoid mefloquine
-Allergic to mefloquine or related compounds (quinidine, quinine) -Active/recent depression -Recent hx of psychiatric disorders/seizures -Cardiac conduction abnormality
36
Primaquine duration
Begin 1-2 days before departure & continue for 7 days after leaving malaria endemic area
37
Primaquine counseling points
-Take WF to minimize GI upset -SE: GI disturbance
38
Primaquine pros/cons
Pros -Good for last minute travel -Good at preventing P. vivax (ONLY USE FOR PLACES WITH > 90% P. VIVAX) Cons -Costs and delays associated with G6PD testing **Deficiency in G6PD --> severe hemolytic anemia **Cannot administer primaquine until G6PD test is complete
39
Reasons to avoid using primaquine
-G6PD deficiency -Have not been tested for G6PD -Women who are pregnant -Women who are breastfeeding unless infant is tested for G6PD deficiency
40
Tafenoquine duration
Begin 3 days before departure & continue 1 week after leaving malaria endemic region
41
Tafenoquine counseling points
-Take WF to minimize GI upset -SE: GI disturbance, HA, dizziness
42
Tafenoquine pros/cons
Pros -Good for last minute travel -Can be used in all malaria endemic regions Cons -Costs & delays associated with G6PD testing -Not indicated for use in children
43
Reasons to avoid Tafenoquine
-G6PD deficiency -Have not been tested for G6PD -Women who are pregnant -Women who are breastfeeding unless infant is tested for G6PD deficiency -Children -PSYCHOTIC DISORDERS (C/I)
44
Clues for malaria
When a pt presents with fever AND has traveled to a malaria endemic region before fever onset (within the previous 3 months)
45
Malaria symptom onset
-Typically 2-4 weeks after mosquito bite -Can occur up to 3 years after exposure to P. vivax or P. ovale due to dormant stage of those
46
Clinical symptoms of malaria
-Fever -HA -Weakness -Rigors -Night sweats -Insomnia -Arthralgias/myalgias -GI distress (N/V/D) -Neurological complications (dizziness, confusion, disorientation, coma)
47
Lab findings of malaria
-Anemia (RBC lysing; RBC sequestering into organs) -Thrombocytopenia -Hyponatremia -Acidemia -Increased creatinine -Hypoglycemia
48
Diagnosis of malaria is based on ______
BLOOD SMEAR -Thick smear: RBCs are lysed so visualize parasite outside of cells (to estimate parasite density) -Thin smear: used to determine Plasmodium spp **Check blood smear every 12-24H x 3 to rule out malaria Rapid diagnostic test -Detection of Plasmodium histidine-rich protein-2 (HRP-2)
49
Why consideration of the plasmodium spp is important
-P. falciparum and P. knowlesi are more likely to progress to severe disease/death --> admit to hospital -P. falciparum and P. vivax have different drug resistance patterns in various regions -P. vivax and P. ovale also require tx for hypnozoites (dormant liver stage)
50
How to classify a patient as having severe malaria
-Impaired consciousness/coma -Hemoglobin < 7 g/dL -Acute kidney injury (AKI) -Acute respiratory distress syndrome (ARDS) -Circulatory collapse/shock -Acidosis -Disseminated intravascular coagulation -Parasite density >/= 5% **Only have to have 1 of these **Typically cause by P. falciparum
51
Tx for uncomplicated malaria -Presence of chloroquine resistance or unknown resistance
Artemether-lumefantrine (Coartem) -- DOC Atovaquone-proguanil (Malarone) **Both are 3-day regimens Quinine sulfate + Doxy, tetra, or clinda x 10 days Mefloquine (if no other options available)
52
Counseling points for Artemether-lumefantrine
-Take with food/milk -Repeat dose if vomits within 30 mins of taking dose -SE: N/V/D, HA, dizziness, fever, myalgia
53
Counseling points for atovaquone-proguanil (Malarone)
-Take with food/milk -Repeat dose if vomits within 30 mins of taking dose -SE: N/V, abdominal pain, increased LFTs
54
Counseling points for Quinine sulfate + Doxy, tetra, or clinda
Quinine SE: HA, dizziness, blurred vision, arrythmia, QTc prolongation, hypotension Tetracycline: wear sunscreen, separate from cations; not for children < 8 y/o -SE: Diarrhea, abdominal pain, photosensitivity, vulvovaginal candidiasis Clindamycin: Diarrhea, C. diff infection
55
Tx for uncomplicated malaria -Presence of chloroquine resistance, no mefloquine or unknown resistance
Mefloquine (LAST LINE if no other options) -2 doses
56
Counseling points with mefloquine
-Has been associated with rare, but serious rxn (psychosis/seizure) -SE: abnormal dreams, anxiety, depression, dizziness, GI disturbance, HA, insomnia, visual disturbance -AVOID if hx of psychiatric disorders/seizure
57
Tx for uncomplicated malaria -Chloroquine sensitive
-Chloroquine -Hydroxychloroquine *4 doses
58
Chloroquine SE
-Blurred vision -Dizziness -GI disturbance -HA -Insomnia -Pruritus
59
Hydroxychloroquine SE
-Blurred vision -Dizziness -GI disturbance -HA -Insomnia -Pruritus
60
Anti-relapse tx (for dormant liver stage) -For P. vivax and P. ovale infections
Primaquine phosphate x 14d Tafenoquine (Krintafel) x 1 dose
61
Primaquine phosphate counseling points
-Need G6PD testing before use (only use if G6PD normal) -SE: GI disturbance, HA, hemolysis ***MUST ADD PRIMAQUINE IF P. OVALE OR P. VIVAX & CHLOROQUINE-'R'
62
Tafenoquine (Krintafel) counseling points
-Need G6PD testing before use (only use if G6PD normal) -SE: GI disturbance, HA, hemolysis (MAY be delayed due to long half-life) *AVOID if hx of psychiatric disorder ***MUST ADD PRIMAQUINE OR TAFENOQUINE FOR P. OVALE OR P. VIVAX & CHLOROQUINE-'R' ***TAFENOQUINE CAN ONLY BE USED IN PT RECEIVED CHLOROQUINE FOR TX
63
Tx for uncomplicated malaria -P. knowlesi or P. malariae
Chloroquine or hydroxychloroquine are preferred Alternatives: -Artemether-lumefantrine -Atovaquone-proguanil -Quinine + tetra, doxy, or clinda -Mefloquine (if no other options)
64
Tx of severe malaria
-Perform blood smears Q12-24H until negative -Can be fatal, so initiate tx ASAP -TX ~IV artesunate (continue until parasite density
65
IV Artesunate comments
-EXPENSIVE!!! -Many hospitals do not carry so need to urgently contact CDC, distributor, or other hospitals to get ASAP -While waiting, tx with oral tx option including: artemether-lumefantrine, atovaquone-proguanil, quinine + doxycyline or clinda, or mefloquine -SE: delayed post-artemisinin hemolytic anemia *Rare, but higher likelihood if high parasite density *After use if IV artesunate get weekly CBCs for 4 weeks to monitor

Exam 5 - Therapeutics (11 decks)

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