Falciparum malaria
▶BY MOUTH
▶Child: 10 mg/kg every 8 hours (max. per dose 600 mg)
for 7 days, to be given together with or followed by
either doxycycline (in children over 12 years), or
clindamycin
▶BY INTRAVENOUS INFUSION
▶Neonate:Loading dose 20 mg/kg, infused over 4 hours,
the loading dose of 20 mg/kg shouldnotbe used if the
patient has received quinine or mefloquine during the
previous 12 hours, then maintenance 10 mg/kg every
8 hours until patient can swallow oral medication to
complete the 7 -day course, maintenance dose to be
given 8 hours after the start of the loading dose and
infused over 4 hours, to be given together with or
followed by clindamycin, reduce maintenance dose to
5 – 7 mg/kg if parenteral treatment is required for more
than 48 hours.▶Child:Loading dose 20 mg/kg (max. per dose 1. 4 g),
infused over 4 hours, the loading dose of 20 mg/kg
shouldnotbe used if the patient has received quinine
or mefloquine during the previous 12 hours, then
maintenance 10 mg/kg every 8 hours (max. per dose
700 mg) until patient can swallow tablets to complete
the 7 -day course, maintenance dose to be given
8 hours after the start of the loading dose and infused
over 4 hours, to be given together with or followed by
either doxycycline (in children over 12 years), or
clindamycin, reduce maintenance dose to 5 – 7 mg/kg if
parenteral treatment is required for more than
48 hours
Falciparum malaria (in intensive care unit)
▶BY INTRAVENOUS INFUSION
▶Neonate:Loading dose 7 mg/kg, infused over
30 minutes, followed immediately by 10 mg/kg, infused
over 4 hours, then maintenance 10 mg/kg every 8 hours
until patient can swallow oral medication to complete
the 7 -day course, maintenance dose to be given 8 hours
after the start of the loading dose and infused over
4 hours, to be given together with or followed by
clindamycin, reduce maintenance dose to 5 – 7 mg/kg if
parenteral treatment is required for more than 48 hours.▶Child:Loading dose 7 mg/kg, infused over 30 minutes,
followed immediately by 10 mg/kg, infused over
4 hours, then maintenance 10 mg/kg every 8 hours
(max. per dose 700 mg) until patient can swallow
tablets to complete the 7 -day course, maintenance
dose to be given 8 hours after the start of the loading
dose and infused over 4 hours, to be given together
with or followed by either doxycycline (in children over
12 years), or clindamycin, reduce maintenance dose to
5 – 7 mg/kg if parenteral treatment is required for more
than 48 hours
DOSE EQUIVALENCE AND CONVERSION
▶When using quinine for malaria, doses are valid for
quinine hydrochloride, dihydrochloride, and sulfate;
they arenot validfor quinine bisulfate which contains
a correspondingly smaller amount of quinine.
▶Quinine (anhydrous base) 100 mg = quinine bisulfate
169 mg; quinine dihydrochloride 122 mg; quinine
hydrochloride 122 mg; and quinine sulfate 121 mg.
Quinine bisulfate 300 mg tablets are available but
provide less quinine than 300 mg of the
dihydrochloride, hydrochloride, or sulfate.lUNLICENSED USEInjection not licensed.IMPORTANT SAFETY INFORMATION
MHRA/CHM ADVICE: REMINDER OF DOSE-DEPENDENT QT-
PROLONGING EFFECTS (NOVEMBER 2017)
Quinine has been associated with dose-dependent QT-
interval-prolonging effects and should be used with
caution in patients with risk factors for QT prolongation
or in those with atrioventricular block—see Cautions for
further information.lCONTRA-INDICATIONSHaemoglobinuria.myasthenia
gravis.optic neuritis.tinnitus
lCAUTIONSAtrialfibrillation (monitor ECG during
parenteral treatment).cardiac disease (monitor ECG
during parenteral treatment).conduction defects (monitor
ECG during parenteral treatment).electrolyte disturbance
.G6PD deficiency.heart block (monitor ECG during
parenteral treatment)
lINTERACTIONS→Appendix 1 : antimalarials
lSIDE-EFFECTSAbdominal pain.agitation.agranulocytosis
.angioedema.asthma.atrioventricular conduction
changes.bronchospasm.cardiotoxicity.cerebral
impairment.coagulation disorders.coma.confusion.
death.diarrhoea.dyspnoea.fever.flushing.
gastrointestinal disorder.haemoglobinuria.haemolysis.
haemolytic uraemic syndrome.headache.hearing
impairment.hypersensitivity.loss of consciousness.
muscle weakness.myasthenia gravis aggravated.nausea.
ocular toxicity.oedema.pancytopenia.photosensitivity
reaction.QT interval prolongation.renal impairment.
skin reactions.thrombocytopenia.vertigo.vision
disorders.vomiting
Overdose Quinine is very toxic in overdosage; life-
threatening features include arrhythmias (which can have
a very rapid onset) and convulsions (which can be
intractable).
For details on the management of poisoning, see
Emergency treatment of poisoning p. 832.
lPREGNANCYHigh doses are teratogenic infirst trimester,
but in malaria benefit of treatment outweighs risk.
lBREAST FEEDINGPresent in milk but not known to be
harmful.
lHEPATIC IMPAIRMENT
Dose adjustments▶With intravenous useFor treatment of
malaria in severe impairment, reduce parenteral
maintenance dose to 5 – 7 mg/kg of quinine salt.
lRENAL IMPAIRMENT
Dose adjustments▶With intravenous useFor treatment of
malaria in severe impairment, reduce parenteral
maintenance dose to 5 – 7 mg/kg of quinine salt.
lMONITORING REQUIREMENTSMonitor blood glucose and
electrolyte concentration during parenteral treatment.
lDIRECTIONS FOR ADMINISTRATIONForintravenous
infusion, dilute to a concentration of 2 mg/mL (max.
30 mg/mL influid restriction) with Glucose 5 %orSodium
Chloride 0. 9 % and give over 4 hours.
lPRESCRIBING AND DISPENSING INFORMATIONIntravenous
injection of quinine is so hazardous that it has been
superseded by infusion.lMEDICINAL FORMS
There can be variation in the licensing of different medicines
containing the same drug. Forms available from special-order
manufacturers include: capsule, oral suspension, oral solution,
solution for infusion
Tablet
▶Quinine (Non-proprietary)
Quinine sulfate 200 mgQuinine sulfate 200 mg tablets|
28 tabletP£ 2. 90 DT = £ 1. 43
Quinine bisulfate 300 mgQuinine bisulfate 300 mg tablets|
28 tabletP£ 2. 57 DT = £ 1. 94398 Protozoal infection BNFC 2018 – 2019
Infection5