UptoDate: Treatment of uncomplicated
falciparum malaria in nonpregnant adults and children
[Updated at 31 July
2019]
Gametocytes may persist in the blood after successful treatment
of infection; they are not harmful to the patient but serve as a source of ongoing
transmission. Artemether-lumefantrine has been shown to be superior to
non-artemisinin antimalarial drugs in reducing gametocytemia. Primaquine has
activity against mature gametocytes but no effect on blood-stage parasites.
To further reduce transmissibility of treated P. falciparum
infection in endemic areas with low transmission, we are in agreement with the
WHO which favors administration of primaquine (0.25 mg/kg single dose) on the
first day of malaria treatment to nonpregnant adults and children ≥6
months. This approach is supported by a systematic review including 24
randomized trials in which a single low dose of primaquine added to ACT therapy
reduced infectiousness of humans to mosquitoes on day 3 or 4 (from 14 to 2
percent) and was as effective as higher doses of primaquine. Data on the impact
on community transmission levels and hemolysis in glucose-6-phosphate
dehydrogenase (G6PD) deficiency are needed. Primaquine should be avoided in
pregnant women and infants <6 months of age given the particular
vulnerability of these patient groups.
Primaquine can cause hemolysis in individuals with G6PD
deficiency; however, G6PD testing is not required for patients receiving
primaquine for reducing transmissibility given the relatively low dose for this
indication. In one study including 274 Senegalese patients with mild malaria
randomized to ACT plus primaquine (0.25 mg/kg, single dose) versus ACT alone,
the mean reduction in hemoglobin at day 7 was equivalent. Among 54 patients
with G6PD deficiency, the drop in hemoglobin was 0.63 g/dL greater in those who
received primaquine than in those who received an ACT alone.
World Health
Organisation: Guidelines for the Treatment of Malaria (3rd Edition,
2015)
In
low-transmission areas, give a single dose of 0.25 mg/kg bw primaquine with ACT
to patients with P. falciparum malaria (except pregnant women, infants aged
< 6 months and women breastfeeding infants aged < 6 months) to reduce
transmission. Testing for glucose-6-phosphate dehydrogenase (G6PD) deficiency
is NOT required.
(Strong recommendation, low quality evidence)
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