InternPractice — Always a Step Ahead

Medicinal Forms

There can be variation in the licensing of different medicines containing the same drug. Solution for injection ▶Pentostam (GlaxoSmithKline UK Ltd) Antimony pentavalent (as Sodium stibogluconate) 100 mg per 1 ml Pentostam 10g/100ml solution for injection vials | 1 vial P £66.43 5.2 Malaria Antimalarials Artemether with lumefantrine Artemether with lumefantrine p. 650 is licensed for the treatment of acute uncomplicated falciparum malaria. Artenimol with piperaquine Artenimol with piperaquine phosphate p. 650 is not recommended for the ﬁrst-line treatment of acute uncomplicated falciparum malaria because there is limited experience of its use in travellers who usually reside in areas where malaria is not endemic. Piperaquine has a long half- life. Atovaquone with proguanil Atovaquone with proguanil hydrochloride p. 651 is licensed for the prophylaxis of falciparum malaria (for details, see Recommended regimens for prophylaxis against malaria p. 644) and for the treatment of acute, uncomplicated falciparum malaria. Chloroquine Chloroquine p. 651 is usually used with proguanil hydrochloride p. 654 for the prophylaxis of malaria in areas of the world where there is little chloroquine resistance (for details, see Recommended regimens for prophylaxis against malaria p. 644). Guidelines for malaria prevention in travellers from the United Kingdom (2019) published by Public Health England state that patients already taking hydroxychloroquine sulfate p. 1156 for another indication, and for whom chloroquine would be an appropriate antimalarial, can remain on hydroxychloroquine sulfate. Chloroquine is no longer recommended for the treatment of falciparum malaria owing to widespread resistance, nor is it recommended if the infective species is not known or if the infection is mixed; in these cases treatment should be with quinine p. 655, atovaquone with proguanil hydrochloride p. 651, or artemether with lumefantrine. It is still recommended for the treatment of non-falciparum malaria. Doxycycline Doxycycline p. 597 is used in adults and children over 12 years as an option for the prophylaxis of malaria in areas of chloroquine resistance. Doxycycline is also used as an alternative to meﬂoquine p. 653 or atovaquone with proguanil hydrochloride p. 651, (for details, see Recommended regimens for prophylaxis against malaria p. 644). Mefloquine Meﬂoquine is used for the prophylaxis of malaria in areas of chloroquine resistance. Meﬂoquine is also used as an alternative to doxycycline or atovaquone with proguanil hydrochloride p. 651, (for details, see Recommended regimens for prophylaxis against malaria p. 644). Meﬂoquine is now rarely used for the treatment of falciparum malaria because of increased resistance. It is rarely used for the treatment of non-falciparum malaria because better tolerated alternatives are available. Meﬂoquine should not be used for treatment if it has been used for prophylaxis. Primaquine Primaquine p. 654 is used to eliminate the liver stages of P. vivax or P. ovale following chloroquine treatment. Proguanil Proguanil hydrochloride is usually used in combination with chloroquine or atovaquone for the prophylaxis of malaria, (for details, see Recommended regimens for prophylaxis against malaria p. 644). Proguanil hydrochloride used alone is not suitable for the treatment of malaria; however, atovaquone with proguanil hydrochloride p. 651 is licensed for the treatment of acute uncomplicated falciparum malaria. Atovaquone with proguanil hydrochloride p. 651 is also used for the prophylaxis of falciparum malaria in areas of chloroquine resistance. Atovaquone with proguanil hydrochloride p. 651 is also used as an alternative to meﬂoquine or doxycycline. Atovaquone with proguanil hydrochloride p. 651 is particularly suitable for short trips to chloroquine-resistant areas because it needs to be taken only for 7 days after leaving an endemic area. Pyrimethamine Pyrimethamine p. 656 should not be used alone, but is used with sulfadoxine. Pyrimethamine with sulfadoxine can be used in the treatment of falciparum malaria with (or following) quinine. Quinine Quinine is used for the treatment of falciparum malaria, if the infective species is not known, or if the infection is mixed (for details see Malaria, treatment p. 649). Useful resources Recommendations on prophylaxis against malaria reﬂect guidelines agreed by the Advisory Committee on Malaria Prevention (ACMP), published in the Public Health England (PHE) Guidelines for malaria prevention in travellers from the United Kingdom, 2019. The advice is aimed at residents of the UK who travel to endemic areas. www.gov.uk/ government/publications/malaria-prevention-guidelines-for- travellers-from-the-uk Malaria, prophylaxis Prophylaxis against malaria The recommendations on prophylaxis reﬂect guidelines agreed by the Advisory Committee on Malaria Prevention (ACMP), published in the Public Health England (PHE) Guidelines for malaria prevention in travellers from the United Kingdom, 2019. The advice is aimed at residents of the UK who travel to endemic areas. For specialist centres offering advice on speciﬁc malaria- related problems, see Malaria, treatment p. 649. The choice of drug for a particular individual should take into account: . risk of exposure to malaria . extent of drug resistance . efﬁcacy of the recommended drugs . side-effects of the drugs . patient-related factors (e.g. age, pregnancy, renal or hepatic impairment, compliance with prophylactic regimen) For more information on choice of drug, see also Antimalarials p. 642. Protection against bites Prophylaxis is not absolute, and breakthrough infection can occur with any of the drugs recommended. Personal protection against being bitten is very important and is recommended even in malaria-free areas as a preventive measure against other insect vector-borne diseases. Mosquito nets impregnated with a pyrethroid insecticide, such as permethrin p. 1303, improves protection against insects and should be used if sleeping outdoors or in unscreened lodging; vaporised insecticides are also useful. Long sleeves and trousers worn after dusk also provide Infection protection against bites. Insect repellents give protection against bites, but attention to the correct application of product is required. Diethyltoluamide (DEET) 20–50% (available in various preparations including sprays and modiﬁed-release polymer formulations) is safe and effective when applied to the skin of adults and children over 2 months of age. It can also be used during pregnancy and breast-feeding. However, ingestion should be avoided, therefore breast-feeding mothers should wash their hands and breast tissue before handling infants. The duration of protection varies according to the concentration of DEET and is longest for DEET 50%. When sunscreen is also required, DEET should be applied after the sunscreen. DEET reduces the SPF of sunscreen, so a sunscreen of SPF 30–50 should be applied. If DEET is not tolerated or is unavailable, for alternative options, see Public Health England Guidelines for malaria prevention in travellers from the United Kingdom (see Useful resources). Length of prophylaxis Prophylaxis should generally be started before travel into an endemic area; 1 week before travel for chloroquine p. 651 and proguanil hydrochloride p. 654; 2–3 weeks before travel for meﬂoquine p. 653; and 1–2 days before travel for atovaquone with proguanil hydrochloride p. 651 or doxycycline p. 597. Prophylaxis should be continued for 4 weeks after leaving the area (except for atovaquone with proguanil hydrochloride prophylaxis which should be stopped 1 week after leaving). For extensive journeys across different regions, the traveller must be protected in all areas of risk. In those requiring long-term prophylaxis, chloroquine and proguanil hydrochloride may be used. However, there is considerable concern over the protective efﬁcacy of the combination of chloroquine and proguanil hydrochloride in certain areas where it was previously useful. Meﬂoquine is licensed for use up to 1 year (although, if it is tolerated in the short term, there is no evidence of harm when it is used for up to 3 years). Doxycycline can be used for up to 2 years, and atovaquone with proguanil hydrochloride for up to 1 year. Prophylaxis with meﬂoquine, doxycycline, or atovaquone with proguanil hydrochloride may be considered for longer durations if it is justiﬁed by the risk of exposure to malaria. Specialist advice may be sought for long-term prophylaxis. Return from malarial region It is important to consider that any illness that occurs within 1 year and especially within 3 months of return might be malaria even if all recommended precautions against malaria were taken. Travellers should be warned of this and told that if they develop any illness after their return they should see a doctor early, and speciﬁcally mention their risk of exposure to malaria. Epilepsy Both chloroquine and meﬂoquine are unsuitable for malaria prophylaxis in individuals with a history of epilepsy. In these patients, doxycycline or atovaquone with proguanil hydrochloride may be used. However doxycycline may interact with some antiepileptics and its dose may need to be adjusted, see interactions information for doxycycline. Asplenia Asplenic individuals (or those with severe splenic dysfunction) are at particular risk of severe malaria. If travel to malarious areas is unavoidable, rigorous precautions are required against contracting the disease. Key to recommended regimens for prophylaxis against malaria Codes for regimens Details of regimens for prophylaxis against malaria No risk - Chemoprophylaxis not recommended, but avoid mosquito bites and consider malaria if fever presents Chloroquine only Chloroquine with proguanil Infection Atovaquone with proguanil hydrochloride or doxycycline or mefloquine Speciﬁc recommendations Country Comments on risk of malaria and regional or seasonal variation Low risk below 2000 m from May–November Afghanistan Very low risk below 2000 m from December–April Algeria No risk Andaman and Nicobar Islands Low risk (India) Angola High risk Argentina No risk Armenia No risk Azerbaijan Very low risk Bangladesh High risk in Chittagong Hill Tract districts (but not Chittagong city) Very low risk in Chittagong city and other areas, except Chittagong Hill Tract districts Belize Low risk in rural areas No risk in Belize district (including Belize city and islands) Benin High risk Bhutan Low risk in southern belt districts, along border with India: Chukha, Geyleg-phug, Samchi, Samdrup Jonkhar, and Shemgang No risk in areas other than those above Bolivia Low risk in Amazon basin Low risk in rural areas below 2500 m (other than above) No risk above 2500 m High risk from November–June in northern half, including Okavango Delta area Botswana Low risk from July–October in northern half, including Okavango Delta area Very low risk in southern half Brazil Low risk in Amazon basin, including city of Manaus Very low risk in areas other than those above No risk in Iguaçu Falls Brunei Darussalam Very low risk Burkina Faso High risk Burundi High risk Cambodia Low risk. Mefloquine resistance widespread in western provinces bordering Thailand Very low risk in Angkor Wat and Lake Tonle Sap, including Siem Reap No risk in Phnom Penh Cameroon High risk Cape Verde Individuals travelling to Praia who are at increased risk of malaria (such as long- term travellers and those at risk of severe complications from malaria including pregnant women, infants and young children, the elderly, and asplenic individuals) should consider taking antimalarials, seek advice from a travel health advisor.Very low risk on island of Santiago (Sao Tiago) and Boa Vista Central African Republic High risk Chad High risk Codes for regimens - - - - - Country Comments on risk of malaria and regional or seasonal variation China Low risk in Yunnan and Hainan provinces Very low risk in southern and some central provinces, including Anhui, Ghuizhou, Hena, Hubei, and Jiangsu below 1500 m Very low risk in areas other than those above and below No risk in Hong Kong Low risk in rural areas below 1600 m Colombia Very low risk above 1600 m and in Cartagena Comoros High risk Congo High risk Costa Rica Low risk in Limon province, but not city of Limon (Puerto Limon) Very low risk in areas other than those above Cote d’Ivoire (Ivory Coast) High risk Democratic Republic of the High risk Congo Djibouti High risk Dominican Republic Low risk No risk in cities of Santiago and Santo Domingo East Timor (Timor-Leste) Risk present Low risk in areas below 1500 m including coastal provinces and Amazon basin Ecuador No risk in Galapagos islands or city of Guayaquil Egypt No risk El Salvador Low risk in rural areas of Santa Ana, Ahuachapán, and La Unión provinces in western part of country Very low risk in areas other than those above Equatorial Guinea High risk High risk below 2200 m Eritrea No risk in Asmara or in areas above 2200 m High risk below 2000 m Ethiopia No risk in Addis Ababa or in areas above 2000 m Risk present (particularly in border areas) except city of Cayenne or Devil’s Island French Guiana (Ile du Diable) Low risk in city of Cayenne or Devil’s Island (Ile du Diable) Gabon High risk Gambia High risk Very low risk from June–October in rural south east Georgia No risk from November–May in rural south east Ghana High risk Low risk below 1500 m Guatemala No risk in Guatemala City, Antigua, or Lake Atitlan and above 1500 m Guinea High risk Guinea-Bissau High risk Guyana Risk present in all interior regions Very low risk in Georgetown and coastal region Haiti Risk present Low risk below 1000 m and in Roatán and other Bay Islands Honduras No risk in San Pedro Sula or Tegucigalpa and areas above 1000 m India Risk present in states of Assam and Orissa, districts of East Godavari, Srikakulam, Vishakhapatnam, and Vizianagaram in the state of Andhra Pradesh, and districts of Balaghat, Dindori, Mandla, and Seoni in the state of Madhya Pradesh Low risk in areas other than those above or below (including Goa, Andaman and Nicobar islands) Exceptional circumstances in low risk areas (dependent on individual risk assessment) No risk in Lakshadweep islands Codes for regimens - Infection - - - - - - - - Key to recommended regimens for prophylaxis against malaria Codes for regimens Details of regimens for prophylaxis against malaria No risk - Chemoprophylaxis not recommended, but avoid mosquito bites and consider malaria if fever presents Chloroquine only Chloroquine with proguanil Infection Atovaquone with proguanil hydrochloride or doxycycline or mefloquine Speciﬁc recommendations Country Comments on risk of malaria and regional or seasonal variation Indonesia High risk in Irian Jaya (Papua) Low risk in Bali, Lombok and islands of Java and Sumatra No risk in city of Jakarta Indonesia (Borneo) Low risk Low risk from March–November in rural south eastern provinces and in north, along Iran Azerbaijan border in Ardabil, and near Turkmenistan border in North Khorasan Very low risk in areas other than those above Very low risk from May–November in rural northern area below 1500 m Iraq No risk in areas other than those above Kenya High risk (except city of Nairobi) Very low risk in the highlands above 2500 m and in city of Nairobi Kyrgyzstan No risk Lao People’s Democratic Low risk Republic (Laos) Very low risk in city of Vientiane Liberia High risk Libya No risk Madagascar High risk Malawi High risk Malaysia Low risk in mainland Malaysia Malaysia (Borneo) Low risk in inland areas of Sabah and in inland, forested areas of Sarawak Very low risk in areas other than those above, including coastal areas of Sabah and Sarawak Mali High risk High risk all year in southern provinces, and from July–October in the northern Mauritania provinces Low risk from November–June in the northern provinces Mauritius No risk Mayotte Risk present Mexico Very low risk Mozambique High risk Myanmar Low risk Namibia High risk all year in regions of Caprivi Strip, Kavango, and Kunene river, and from November–June in northern third of country Low risk from July–October in northern third of country, except as above in regions of Caprivi Strip, Kavango, and Kunene river Very low risk in areas other than those above Low risk below 1500 m, including the Terai district Nepal No risk in city of Kathmandu and on typical Himalayan treks Nicaragua Low risk (except Managua) Very low risk in Managua Niger High risk Nigeria High risk North Korea Very low risk in some southern areas Codes for regimens - - - - Country Comments on risk of malaria and regional or seasonal variation Low risk below 2000 m Pakistan Very low risk above 2000 m Panama Low risk east of Canal Zone Very low risk west of Canal Zone No risk in Panama City or Canal Zone itself High risk below 1800 m Papua New Guinea Very low risk above 1800 m Paraguay No risk Peru Low risk in Amazon basin along border with Brazil, particularly in Loreto province and in rural areas below 2000 m including the Amazon basin bordering Bolivia No risk in city of Lima and coastal region south of Chiclayo Low risk in rural areas below 600 m and on islands of Luzon, Mindanao, Mindoro, Philippines and Palawan No risk in cities or on islands of Boracay, Bohol, Catanduanes, Cebu, or Leyte Rwanda High risk São Tomé and Principe High risk Saudi Arabia Low risk in south-western provinces along border with Yemen, including below 2000 m in Asir province No risk in cities of Jeddah, Makkah (Mecca), Medina, Riyadh, or Ta’if, or above 2000 m in Asir province Senegal High risk Sierra Leone High risk Singapore No risk Solomon Islands High risk Somalia High risk Risk from September–May in low altitude areas of Mpumalanga and Limpopo, South Africa particularly those bordering Mozambique, Swaziland (Estwatini), and Zimbabwe (including Kruger National Park) Low risk in north-east KwaZulu-Natal and in designated areas of Mpumalanga and Limpopo Very low risk in North West Province (adjacent to Molopo river) and Northern Cape Province (adjacent to Orange river) South Korea Very low risk in northern areas, in Gangwon-do and Gyeonggi-do provinces, and Incheon city (towards Demilitarized Zone) South Sudan High risk Sri Lanka No risk Sudan High risk in central and southern areas; risk also present in rest of country (except Khartoum) Very low risk in Khartoum Suriname Risk present on the French Guiana border Low risk in areas other than above and below No risk in city of Paramaribo Swaziland Risk in northern and eastern regions bordering Mozambique and South Africa, including all of Lubombo district and Big Bend, Mhlume, Simunye, and Tshaneni regions Very low risk in the areas other than those above Syria Very low risk in small, remote foci of El Hasakah Tajikistan Very low risk No risk above 2000 m High risk below 1800 m; risk also in Zanzibar Tanzania No risk above 1800 m Thailand Mefloquine resistance present. Low risk in rural forested borders with Cambodia, Laos, and Myanmar Very low risk in areas other than those above, including Kanchanaburi (Kwai Bridge) No risk in cities of Bangkok, Chiang Mai, Chiang Rai, Koh Phangan, Koh Samui, and Pattaya Codes for regimens - Infection - - - - - - - Key to recommended regimens for prophylaxis against malaria Codes for regimens Details of regimens for prophylaxis against malaria No risk - Chemoprophylaxis not recommended, but avoid mosquito bites and consider malaria if fever presents Chloroquine only Chloroquine with proguanil Infection Atovaquone with proguanil hydrochloride or doxycycline or mefloquine Speciﬁc recommendations Country Comments on risk of malaria and regional or seasonal variation Togo High risk Turkey Very low risk Uganda High risk Uzbekistan No risk Vanuatu Risk present Venezuela Risk in all areas south of, and including, the Orinoco river and Angel Falls, rural areas of Apure, Monagas, Sucre, and Zulia states Increase in reported malaria cases between 2010 and 2017, mainly in the Bolivar state No risk in city of Caracas or on Margarita Island Vietnam Low risk in rural areas, and in southern provinces of Tay Ninh, Lam Dong, Dac Lac, Gia Lai, and Kon Tum No risk in large cities (including Ho Chi Minh City (Saigon) and Hanoi), the Red River delta, coastal areas north of Nha Trang and Phu Quoc Island Western Sahara No risk Risk below 2000 m Yemen Very low risk on Socrota Island No risk above 2000 m, including Sana’a city Zambia High risk High risk all year in Zambezi valley, and from November–June in areas below Zimbabwe 1200 m Low risk from July–October in areas below 1200 m Very low risk all year in Harare and Bulawayo Pregnancy Travel to malarious areas should be avoided during pregnancy; if travel is unavoidable, pregnant individuals must be informed about the risks and beneﬁts of effective prophylaxis. Chloroquine and proguanil hydrochloride can be given in the usual doses during pregnancy, but these drugs are not appropriate for most areas because their effectiveness has declined. In the case of proguanil hydrochloride, folic acid p. 1084 (dosed as a pregnancy at ’high-risk’ of neural tube defects) should be given for the length of time that it is used during pregnancy. If travelling to high risk areas or there is resistance to other drugs, meﬂoquine may be considered during the second or third trimester of pregnancy. Meﬂoquine can be used in the ﬁrst trimester with caution if the beneﬁts outweigh the risks. Doxycycline is contra-indicated during pregnancy; however, it can be used for malaria prophylaxis if other regimens are unsuitable, and if the entire course of doxycycline can be completed before 15 weeks’ gestation [unlicensed]. Atovaquone with proguanil hydrochloride should be avoided during pregnancy, however, it can be considered during the second and third trimesters if there is no suitable alternative. Folic acid (dosed as a pregnancy at ’high-risk’ of neural tube defects) should be given for the length of time that atovaquone with proguanil hydrochloride is used during pregnancy. Codes for regimens - Breast-feeding Some antimalarials should be avoided when breast feeding, see individual drugs for details. Prophylaxis is required in breast-fed infants; although antimalarials are present in milk, the amounts are too variable to give reliable protection. Anticoagulants Travellers taking warfarin sodium p. 150 should begin chemoprophylaxis 2–3 weeks before departure and the INR should be stable before departure. It should be measured before starting chemoprophylaxis, 7 days after starting, and after completing the course. For prolonged stays, the INR should be checked at regular intervals. There is relatively limited experience of chemoprophylaxis in those travellers taking direct oral anticoagulants (DOACs). Other medical conditions For additional information on malaria prophylaxis in patients with other medical conditions, see Public Health England Guidelines for malaria prevention in travellers from the United Kingdom (see Useful resources). Emergency standby treatment Travellers on prophylaxis and visiting remote, malarious areas should carry standby emergency treatment if they are likely to be more than 24 hours away from medical care. Standby emergency treatment should also be considered in long-term travellers living in or visiting remote, malarious areas that may be far from appropriate medical attention; this does not replace the need to consider prophylaxis. Self- medication should be avoided if medical help is accessible. In order to use standby treatment appropriately, the traveller should be provided with written instructions which include seeking urgent medical attention if fever (38°C or more) develops 7 days (or more) after arriving in a malarious area and that self-treatment is indicated if medical help is not available within 24 hours of fever onset. In view of the continuing emergence of resistant strains and of the different regimens required for different areas expert advice should be sought on the best treatment course for an individual traveller. A drug used for chemoprophylaxis should not be considered for standby treatment for the same traveller due to concerns over drug resistance and to minimise drug toxicity. Malaria prophylaxis, specific recommendations Travellers planning journeys across continents can travel into areas that have different malaria prophylaxis recommendations. The choice of prophylaxis medication must reﬂect overall risk to ensure protection in all areas; it may be possible to change from one regimen to another. Those travelling to remote or little-visited areas may require expert advice. For further information see Recommended regimens for prophylaxis against malaria, and Public Health England Guidelines for malaria prevention in travellers from the United Kingdom (see Useful resources). Important Settled immigrants (or long-term visitors) to the UK may be unaware that any immunity they may have acquired while living in malarious areas is lost rapidly after migration to the UK, or that any non-malarious areas where they lived previously may now be malarious. Useful resources Public Health England guideline: Guidelines for malaria prevention in travellers from the United Kingdom. September 2019. www.gov.uk/government/publications/malaria-prevention- guidelines-for-travellers-from-the-uk Malaria, treatment Advice for healthcare professionals A number of specialist centres are able to provide advice on speciﬁc problems. Public Health England (PHE) Malaria Reference Laboratory (prophylaxis) www.gov.uk/government/collections/malaria- reference-laboratory-mrl National Travel Health Network and Centre (NaTHNaC) 0845 602 6712 www.travelhealthpro.org.uk/ TRAVAX (Health Protection Scotland) 0141 300 1130 www.travax.nhs.uk (for registered users of the NHS Travax website only) Hospital for Tropical Diseases (HTD) (treatment) www.thehtd. org/ Liverpool School of Tropical Medicine (LSTM) (treatment) 0151 705 3100 Monday to Friday: 9 a.m.–5 p.m. and via Royal Liverpool Hospital switchboard at all other times 0151 706 2000 www.lstmed.ac.uk/ Birmingham 0121 424 2358 Your local infectious diseases unit Advice for travellers Hospital for Tropical Diseases Travel Healthline 020 7950 7799 www.fitfortravel.nhs.uk/home WHO advice on international travel and health www.who.int/ ith/en/ National Travel Health Network and Centre (NaTHNaC) www.travelhealthpro.org.uk/ Infection Treatment of malaria Recommendations on the treatment of malaria reﬂect guidelines agreed by UK malaria specialists. If the infective species is not known, or if the infection is mixed, initial treatment should be as for falciparum malaria with quinine p. 655, Malarone ® (atovaquone with proguanil hydrochloride p. 651), or Riamet ® (artemether with lumefantrine p. 650). Falciparum malaria can progress rapidly in unprotected individuals and antimalarial treatment should be considered in those with features of severe malaria and possible exposure, even if the initial blood tests for the organism are negative. Falciparum malaria (treatment) Falciparum malaria (malignant malaria) is caused by Plasmodium falciparum. In most parts of the world P. falciparum is now resistant to chloroquine p. 651 which should not therefore be given for treatment. Quinine, Malarone® (atovaquone with proguanil hydrochloride), or Riamet® (artemether with lumefantrine) can be given by mouth if the patient can swallow and retain tablets and there are no serious manifestations (e.g. impaired consciousness); quinine should be given by intravenous infusion if the patient is seriously ill or unable to take tablets. Meﬂoquine p. 653 is now rarely used for treatment because of concerns about resistance. Oral quinine is given by mouth for 5–7 days, together with or followed by either doxycycline p. 597 for 7 days or clindamycin p. 564 for 7 days [unlicensed]. If the parasite is likely to be sensitive, pyrimethamine with sulfadoxine as a single dose [unlicensed] may be given (instead of either clindamycin or doxycycline) together with, or after, a course of quinine. Alternatively, Malarone ®, or Riamet ® may be given instead of quinine. It is not necessary to give clindamycin, doxycycline, or pyrimethamine with sulfadoxine after Malarone ® or Riamet ® treatment. If the patient is seriously ill or unable to take tablets, or if more than 2% of red blood cell are parasitized, quinine should be given by intravenous infusion[unlicensed] (until patient can swallow tablets to complete the 7-day course together with or followed by either doxycycline or clindamycin). Specialist advice should be sought in difﬁcult cases (e.g. very high parasite count, deterioration on optimal doses of quinine, infection acquired in quinine-resistant areas of south east Asia) because intravenous artesunate may be available for ‘named-patient’ use. Pregnancy Falciparum malaria is particularly dangerous in pregnancy, especially in the last trimester. The adult treatment doses or oral and intravenous quinine (including the loading dose) can safely be given to pregnant women. Clindamycin should be given after quinine [unlicensed indication]. Doxycycline should be avoided in pregnancy (affects teeth and skeletal development); pyrimethamine with sulfadoxine, Malarone ®, and Riamet ® are also best avoided until more information is available. Specialist advice should be sought in difﬁcult cases (e.g. very high parasite count, deterioration on optimal doses of quinine, infection acquired in quinine-resistant areas of south east Asia) because intravenous artesunate may be available for ‘named patient’ use. Non-falciparum malaria (treatment) Non-falciparum malaria is usually caused by Plasmodium vivax and less commonly by P. ovale and P. malariae.P. knowlesi is also present in the Asia-Paciﬁc region. Chloroquine is the drug of choice for the treatment of non- falciparum malaria (but chloroquine-resistant P. vivax has been reported in the Indonesian archipelago, the Malay Peninsula, including Myanmar, and eastward to Southern Infection Vietnam). For the treatment of chloroquine-resistant non-falciparum malaria, Malarone ®[unlicensed indication], quinine, or Riamet ®[unlicensed indication] can be used; as with chloroquine, primaquine p. 654 should be given for radical cure. Chloroquine alone is adequate for P. malariae and P. knowlesi infections but in the case of P. vivax and P. ovale, a radical cure (to destroy parasites in the liver and thus prevent relapses) is required. This is achieved with primaquine [unlicensed] given after chloroquine, with the dose dependent on the infecting organism. For a radical cure, primaquine [unlicensed] is then given for 14 days, with the dose also dependent on the infecting organism. Parenteral Parenteral If the patient is unable to take oral therapy, quinine can be given by intravenous infusion [unlicensed], changed to oral chloroquine as soon as the patient’s condition permits. Pregnancy The adult treatment doses of chloroquine can be given for non-falciparum malaria. In the case of P. vivax or P. ovale, however, the radical cure with primaquine should be postponed until the pregnancy is over; instead chloroquine should be continued, given weekly during the pregnancy. ANTIPROTOZOALS › ANTIMALARIALS

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Medicinal Forms

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Sodium stibogluconate

Overview

Indications And Dose

Cautions

Safety

Interactions

Side Effects

Pregnancy

Breast Feeding

Hepatic Impairment

Renal Impairment

Monitoring Requirements

Dose and formulations

Directions For Administration

Medicinal Forms

Dose text by age group

Sodium stibogluconate

Overview

Indications And Dose

Cautions

Safety

Interactions

Side Effects

Pregnancy

Breast Feeding

Hepatic Impairment

Renal Impairment

Monitoring Requirements

Dose and formulations

Directions For Administration

Medicinal Forms

Dose text by age group