The Who Treatment Protocol for Malaria

8/15/2019 The Who Treatment Protocol for Malaria

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Striking Back at Malaria, Dakar, Senegal 13 September 20062 |

The WHO Guidelines

for the treatment of malaria...

uncomplicated malaria

... provide recommendations for the treatment of :

in special groups (young children, pregnant women, HI !"IDS#

in tra$ellers (%rom non&malaria endemic regions#

in epidemics and comple' emergency situations

se$ere malaria

Not a clinical management manual for the treatment of malaria

Do not deal with preventive uses of antimalarials, such as intermittent preventive

treatment or chemoprophylaxis


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Malaria diagnosis

"...Prompt and accurate diagnosis

of malaria is the key

to effective disease managementand to the reduction of

unnecessary useof antimalarial medicines."


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Striking Back at Malaria, Dakar, Senegal 13 September 2006) |

Malaria diagnosis

*arasitological con%irmation (microscopy or +D# -e%oretreatment

Exceptions: – children under 5 years of age, from areas of high

transmission where treatment is based on clinical

diagnosis

– suspected severe malaria where parasitological

confirmation is not immediately possible


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Striking Back at Malaria, Dakar, Senegal 13 September 2006. |

Treatment

of uncomplicated falciparum malaria

"rtemisinin&-ased com-ination therapies ("/# are the treatmentsrecommended %or all cases o% uncomplicated %alciparum malariaincluding0

– in in%ants,

– in people li$ing with HI!"IDS – %or home&-ased management o% malaria

– pregnant women in the 2nd and rd trimesters

Exception:

• 1st trimester o% pregnancy

only use when there are no alternative effective antimalarials


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Treatment

of uncomplicated falciparum malaria

he %ollowing "/s are presently recommended0

–artemether&lume%antrine

–artesunate 3 amodia4uine

–artesunate 3 me%lo4uine

–artesunate 3 sul%ado'ine&pyrimethamine

e%%icacy o% "/s depend on the e%%icacy o% the partner medicine

he artemisinin derivatives !oral, rectal, or parenteralformulations and partner medicines of #$s are notrecommended as monotherapy for uncomplicated malaria.


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Dihydroartemisinin and *ipera4uine*hosphate is a later addition


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Changing antimalarial treatment policy

reatment failure of !10" #as assessed through monitoring

of therapeutic efficacy at 2$ days%

&ew treatment ' an average cure rate of ! (5" as

assessed in clinical trials


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Treatment

of severe falciparum malaria

)ny of the following antimalarial medicines are recommended

3

– "rtesunate (i7$7 or i7m#

– artemether (i7m7#

– artemotil (i7m#

– 4uinine (i7$7 or i7m#7

% &st choice ' areas of low transmission

%% use when other alternatives not

available

When patient can tolerate oral treatment, give a full

course of ACT or quinine + (clindamycin or

doxycycline)


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Treatment

of severe falciparum malaria

*re&re%erral treatment

Single dose treatment

"rtesunate or artemisinin -y rectaladministration

"rtesunate or artemether (i7m#

9uinine (i7m#


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Treatment of vivax malaria

*hloro+uine prima+uine

-here )* has been adopted for P. falciparum malaria, it may

also be used for P. vivax malaria in combination with

prima+uine

Exception:

– artesunate sulfado.ine/pyrimethamine should not beused


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Antimalarial drug combinations

before ACT

/om-inations o% chemotherapeutic agents can

accelerate therapeutic response, impro$e cure rates and

protect the component drugs against resistance

here are se$eral e'amples o% the success%ul use o%

antimalarial com-inations -e%ore the de$elopment o%

"/, speci%ically 4uinine:tetracycline (or 4uinine:

do'ycycline#, sul%ado'ine:pyrimethamine and, most

recently, ato$a4uone:proguanil


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Why these Combinations ere !nfavorable

-ith each of these combinations, issues have hampered

continued application

uinine'tetracycline is associated with fre+uent side

effects including the nausea, dysphoria, tinnitus and deafness of

cinchonism

has to be given over a long period #'10 days% which can

affect compliance

efficacy is failing in some tropical countries


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or sulfado.ine'pyrimethamine, high/grade

resistance is increasingly encountered

)tova+uone'proguanil is given as a short/course

#3/dose% regimen and is one of the most e.pensiveantimalarial therapies

espite its relatively recent introduction and limited

availability, highly resistant cases have already been

reported


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Candidate partner drugs in ACT In the case o% "/, the artemisinin component pro$ides

a well&tolerated drug with a uni4ue mode o% action that

clears ase'ual %orms 4uickly and has gametocidal

acti$ity

he partner drug should -e one that is also well

tolerated and non&to'ic Must -e present in the -lood at therapeutic

concentrations %or at least se$eral times the duration o%

the parasite li%ecycle ()5 hours in the case o% P.

falciparum#


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TH" #$%"A&' ACT

/omponents ha$e di%%erent modes o% action

;o interactions

Short&course regimens ( days at most#

"t least one drug which clears ase'ual %orms rapidly

"t least one drug with long hal%&li%e (< ) days# =ell tolerated, low to'icity

Broad spectrum o% action (including against

gametocytes# /o%ormulation possi-le

Ine'pensi$e


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"xclusion of partners in ACT

-ut "/ e%%ecti$eness is compromised -y using

%ailing drugs as partners

Despite this situation, =H> has prioritised

artesunate plus amo&dia4uine (a chloro4uine&like drug# and artesunate plus sul%ado'ine:

pyrimethamine as the second&line and third&line

"/ com-inations, respecti$ely


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Documents

The Who Treatment Protocol for Malaria