Aims Of Treatment
Aims |
Causation |
Therapy |
Drugs |
To alleviate symptoms |
Symptoms are caused by blood forms of the parasite |
Blood schizonticidal drugs |
Chloroquine, quinine, pyrimethamine/sulphadoxine, artemisinin |
To prevent relapses
|
Relapses are due to hypnozoites of P. vivax/ P. ovale |
Tissue schizonticidal drugs |
Primaquine |
To prevent spread |
Spread is through the gametocytes |
Gametocytocidal drugs |
Primaquine for P. falciparum, Chloroquine for all other |
Thus, in effect, a blood
schizonticidal drug and primaquine should be administered to ALL types of malaria.
Principles Of Treatment
Treatment of malaria depends
on the following factors:
- Type of infection.
- Severity of infection.
- Status of the host.
- Associated conditions/ diseases.
Type of
infection: Treatment obviously depends on the type of
infection. Patients with P. falciparum malaria should be evaluated thoroughly in
view of potential seriousness of the disease and possibility of resistance to anti
malarial drugs.
P. vivax: Only Chloroquine
25 mg/kg + Primaquine for 14 days.
P. falciparum: Treat
depending on severity & sensitivity. Primaquine as gametocytocidal is a must to
prevent spread.
Mixed infections: Blood
schizonticides as for P. falciparum and Primaquine as for P. vivax.
Severity of
infection: All patients with malaria should be carefully and
thoroughly assessed for complications of malaria. Acute, life-threatening complications
occur only in P. falciparum malaria. Malaria is probably the only disease of its
kind that can be easily treated in just 3 days, yet if the diagnosis and proper treatment
are delayed, it can kill the patient very quickly and easily.
-
All cases of severe malaria should be
presumed to have P. falciparum malaria.
-
If there is any uncertainty about the drug
sensitivity of the parasite, it is safer to treat these cases as chloroquine resistant
malaria with drugs like quinine or artemisinin.
-
All cases of severe malaria should be
admitted to the hospital for proper evaluation, treatment and monitoring.
-
All cases of severe malaria should be
treated with injectable antimalarials (chloroquine, quinine, artemisinin) so as to ensure
adequate absorption and plasma drug levels. It is better to use two blood schizonticidal
drugs, one fast acting and another slow acting, to ensure complete treatment. Newer drugs
available for only oral administration (eg. Mefloquine, Halofantrine) should be avoided.
-
All associated conditions should be
carefully assessed and treated.
Status of the
host: Treatment of malaria is also dependent on host
factors.
-
Patient's age and weight should be recorded
so as to administer adequate doses of anti malarial drugs.
-
Functional capacity- independent, dependent,
bed ridden etc. All patients with severe prostration and who are looking ill should be
admitted to a hospital and monitored.
-
Patients with nausea and vomiting should be
given anti emetic drugs to ensure adequate treatment. While high-grade fever frequently
stimulates vomiting, this may be further aggravated by anti malarial drugs. Therefore it
is better to avoid administration of oral antimalarials at the height of fever. One can
wait for the fever to subside before taking the drugs. If the patient vomits within one
hour of taking the anti malarial drugs, the same should be re-administered. In case of
persistent vomiting, patient should be admitted and vomiting should be controlled with
parenteral anti emetics. Parenteral anti malarials are needed only in cases of severe
malaria or uncontrolled vomiting.
-
Adequate hydration should be ensured.
Associated
conditions/ diseases: Treatment of malaria may have to be modified due to
certain associated conditions/ diseases. Therefore, all such should be carefully assessed
before starting the patient on anti malarial treatment.
-
Pregnancy: Treatment of malaria in
pregnancy may prove to be difficult due to contra indication for use of certain antimalarials. Chloroquine can be used safely in all trimesters of pregnancy. Artemisinin is
not shown to have any deleterious effects on the fetus in animal studies and therefore can
be considered if the situation demands. Quinine can be used in pregnancy, but one should
be watchful about hypoglycemia. Whereas mefloquine is contraindicated in the first
trimester of pregnancy, pyrimethamine/ sulphadoxine is contraindicated in the first and
last trimesters. Halofantrine, tetracycline and doxycycline are absolutely contra
indicated in pregnancy. Primaquine is also contra indicated in pregnancy, and therefore
pregnant women with P. vivax malaria should be started on 500 mg of chloroquine weekly as
suppressive chemoprophylaxis against relapse of malaria.
-
Epilepsy: Malaria as well as anti
malarials can trigger convulsions. Mefloquine is better avoided in these patients. See C.N.S. Disease and malaria
-
Cardiac disease: High-grade fever of
malaria can exacerbate left ventricular failure and therefore, in all such patients
energetic management of malaria is called for. Fever should be controlled with
anti-pyretics and tepid sponging. Chloroquine, artemisinin, pyrimethamine/ sulphadoxine,
tetracyclines and primaquine can be safely used in these patients. Quinine can also be
used carefully. Mefloquine and halofantrine are better avoided in patients with known
cardiac illness. See
C.V.S. Disease and malaria
-
Hepatic insufficiency:
None of the antimalarial drugs have any direct hepatotoxic effect. However, chloroquine is
not advisable in patients with severe hepatic insufficiency. See liver disease and malaria
-
Renal failure: The initial dose of
antimalarial drugs need not be reduced in patients with renal failure. However, if the
patient requires parenteral antimalarials even after three days and continues to be sick,
then the dose can be reduced by one third to half of usual dose. See renal disease and malaria
-
Dermatitis: Concomitant use of
chloroquine with gold salts and phenyl butazone should be avoided because all the three
can cause dermatitis.
Also see myasthenia gravis and malaria, anaesthesia and malaria,
Diabetes and malaria
Modes Of
Treatment: Two important concepts in the treatment of malaria
are suppressive and radical treatments.
Suppressive treatment: The symptoms
of malaria can be alleviated by suppressing the erythrocytic stage of the parasitic
development. Suppressive therapy involves administration of appropriate blood
schizonticidal drugs. In all cases of P. vivax malaria and in most cases of P.
falciparum malaria, it involves administration of chloroquine.
In areas with high transmission of malaria,
it is advisable to practice presumptive treatment for malaria.
What is
presumptive treatment?
Presumption -
In an area with high transmission of malaria, it should be presumed that ALL cases of
fever are due to malaria.
Treatment - First loading dose of
chloroquine should be administered immediately after collecting the blood specimen, even
without waiting for its report.
If the fever is indeed malaria, this
treatment alleviates symptoms early, may be well before the test result is available.
If it is malaria, chloroquine also prevents
the spread of malaria by destroying the gametocytes of P. vivax (the more common
malaria).
If it is not malaria, nothing is lost, for
chloroquine at this dose is safe and has no adverse effects!
Presumptive treatment in areas with high
transmission of P. falciparum malaria: In areas with high transmission of P.
falciparum malaria, chloroquine alone as presumptive treatment may not be enough.
Chloroquine does not sterilize the gametocytes of P. falciparum and thus will not
prevent its spread. Therefore, in areas with high transmission of P. falciparum
malaria, it is recommended to administer the single dose of Primaquine also, along with
chloroquine. Further, in areas with confirmed resistance to chloroquine, therapeutic dose
of pyrimethamine / sulphadoxine can also be administered presumptively. (For dosage of
chloroquine, Primaquine and pyrimethamine / sulphadoxine, see
next page)
Therefore, presumptive
treatment must be practiced by all - it cures early and more important, it prevents spread
of P. vivax malaria.
It is a recommended treatment
under the National Malaria Eradication Programme in India and accordingly, any adverse
effects due to this treatment cannot amount to willful wrong treatment.
Radical treatment:
Radical treatment is administration of primaquine to all confirmed
cases of malaria.
In P. vivax malaria, 2 weeks'
therapy with primaquine completely cures the infection in the host by its tissue
schizonticidal activity and thereby prevents relapses.
In P. falciparum malaria, a single
dose of primaquine destroys the gametocytes, thereby prevents the spread of the infection
into the mosquito.
Therefore, administration of
primaquine is a must in ALL proven cases of malaria, (a two weeks' course in P. vivax malaria
and a single dose in P. falciparum malaria).
Treatment of malaria - Summary |
Type of infection |
Treatment |
|
P.
vivax |
Chloroquine 25 mg
of salt/kg over 36-48 hours + Primaquine for 14 days. |
|
P.
falciparum |
Treatment
depends on severity and sensitivity Chloroquine/Pyrimethamine+sulphadoxine/Quinine/Mefloquine/Artemisinin
and combinations as suppressive therapy + Primaquine as gametocytocidal in single dose |
Mixed
(P. vivax + P.
falciparum) |
Chloroquine or
related drugs as for P. falciparum + Primaquine as for P. vivax |
|
|
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