Treatment of Malaria Quinine is the drug of choice for drug-resistant P. falciparum malaria. In severe illness, the prompt use of loading doses of intravenous quinine (or quinidine, where IV quinine is not available, as in the U.S.) can be lifesaving. Oral medication to maintain therapeutic concentrations then is given as soon as tolerated and continued for 5-7 days. Especially for treatment of infections with multidrug-resistant strains of P. falciparum, slower-acting blood schizon-tocides such as a sulfonamide or a tetracycline are given concurrently to enhance the efficacy of quinine. Formulations of quinine and quinidine and specific regimens for the treatment of P. falciparum malaria are shown in Table 39-2.
The therapeutic range for "free" quinine is 0.2-2.0 mg/L. Regimens to achieve this target may vary based on patient age, severity of illness, and the drug responsiveness of P. falciparum. Lower doses are more effective in treating children in Africa than adults in Southeast Asia because quinine pharmacokinetics differ in these populations, as does the susceptibility of P. falciparum to the drug. Regimens for quinidine are similar to those for quinine, although quinidine binds less to plasma proteins and has a larger volume of distribution, greater systemic clearance, and shorter terminal elimination t1/2 than quinine. The dose of quinidine currently recommended by the Centers for Disease Control and Prevention (CDC), 10 mg salt per kilogram initially, followed by 0.02 mg salt per kilogram per minute, perhaps should be modified to 10 and 0.02 mg of base (60% of the salt is base).
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