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Rectal artesunate (RAS)
Severe malaria patients require parenteral treatment as soon as possible to prevent death or permanent disability. A large scale clinical trial conducted by WHO’s Special Programme for Research and Training in Tropical Diseases (TDR) from 2000 to 2006 demonstrated that for critically ill children who may experience delays of over 6 hours before being able to access parenteral treatment, the administration of an artesunate suppository can diminish mortality from 3.8% (without intervention) to 1.9% (with artesunate suppository).
References
1 Pre-referral rectal artesunate to prevent death and disability in severe malaria: a placebo-controlled trial
2 Cochrane Review: Pre-referral rectal artesunate for severe malaria
Rural areas are often hours away from healthcare facilities that provide the necessary treatment for severe malaria. Delays in treatment will lead to increased severity of symptoms that can lead to death if patients do not reach a facility in time. When parenteral treatment is not available in local health care facility, rectal artesunate can be administered by trained community members to reduce the risk of fatality or complications observed when the initiation of an appropriate treatment in a higher-level health care facility is delayed.
References
1 WHO Guidelines for the treatment of malaria. Third edition 2015.
2 Cochrane Review: Pre-referral rectal artesunate for severe malaria
Injectable artesunate
Clinical evidence from two large-scale, multi-centre trials in South East Asia and Africa showed a reduction in the risk of death by using injectable artesunate of 34.7% in the Asian SEAQUAMAT trial and by 22.5% in the African AQUAMAT trial when compared to parenteral quinine use.
It has been demonstrated that injectable artesunate:
- Saves more lives than quinine
- Is better tolerated than quinine and has fewer side effects
- Is easier to use than quinine, and less painful
References
1 Artesunate versus quinine for Treatment of severe falciparum malaria: a randomised trial
2 Artesunate versus quinine for Treatment of severe falciparum malaria in African Children (AQUAMAT): an open-label, randomised trial
3 Severe hypoglycemia and hyperinsulinemia in falciparum malaria
Parenteral antimalarial agents should be given to pregnant women with severe malaria at any stage of pregnancy, in full doses and without delay. Artesunate is the drug of choice. If this is not available, artemether is preferable to quinine in later pregnancy because quinine is associated with a 50% risk of hypoglycaemia.
References