1. Falciparum Malaria Visit us at : www.drsarma.in
Dr.R.V.S.N.Sarma., M.D., M.Sc.,
Consultant Physician
Tiruvallur
Ph:

2. The Plasmodium species
P.falciparum 15% of Malaria in India
P.vivax Commonest in India
P.malariae Africa and South America
P.ovale African continent

3. Why is falciparum malignant ?
Each cycle releases 20 times more merozoites than vivax
Multiple infestation of RBC
Early hemolysis and endotoxins release, cerebral toxicity
Bilirubin load affects kidneys, liver
Hypovolemia and shock occur
Usually resistant to Chloroquine

4. Differentiation of falciparum
P.falciparum trophozite
P.vivax trophozite

5. Differentiation of falciparum
P.falciparum shizont
P.vivax shizont

6. Differentiation of falciparum
P.falciparum gametocyte
P.vivax gametocyte

7. Electron Micrographs
P.falciparum EM
P.vivax EM

8. Falciparum invading RBC

9. Mangalore story

10. Drug Rx. of falciparum Chloroquine is not the drug of choice
Should not be treated with single drug
Combination therapy is a must
Weaker drugs like Proguanil are of no avail
Artemesinin based CT – ACT is the Rx. of choice

11. The Anti-malarial Drugs
Artesunate, Artether, Artemether
Mefloquine, Amodiaquine
Quinine, Chloroquine
Lumefantrine, Halofantrine,
Proguanilchlor (chlorguanide)
Sulfadoxin+Pyrimethmine, Dapsone
Tetracyclines, Doxycyclin, Clindamycin

12. What is CT ?
Antimalarial combination therapy (CT) is the simultaneous use of two or more blood schizonticidal drugs with different biochemical targets in the parasites and independent modes of action.

13. What is ACT ?
Artemisinin-based combination therapy (ACT) is an antimalarial combination therapy with an artemisinin derivative as one component of the combination given for at least 3 days.

14. Rationale for ACT Resistance to Chloroquine and SP
Protect individual drug from resistance
To decrease rate of decline in efficacy
To interrupt spread of resistant strains
To decrease transmission in a region
The combination is often more effective
In the rare event of resistance to one of the drugs during the course of the infection, the parasite will be killed by the other drug

15. What are Artemisinins ? Artemisinin derivatives Dihydroartemesin
Ethyl Ether
Methyl Ether
Arteether
Artemether
Hemisuccinate
Qinghaosu ("ching-how-soo")
Artesunate

16. Why Artemisinins ? Short half-life; hence good for combination
Rapid substantial reduction of the parasite biomass
Rapid resolution of clinical symptoms
Effective action against multi-drug resistant P. falciparum
Reduction of gametocyte carriage
No documented parasite resistance yet
Few reported adverse effects.

17. ACT - WHO Guidelines
Technical Consultation on Antimalarial Combination Therapy: Geneva, April 2001
Guidelines for the treatment of Malaria
WHO document – 266 page book – February 2006

18. Treatment of uncomplicated P.falciparum malaria

19. Recommended Combinations
Artemether + Lumefantrine (Coartem)
Artesunate (3 days) + Amodiaquine
Artesunate (3 days) + Mefloquine
Artesunate (3 days) + SP
Amodiaquine + SP (as interim option)

20. Artemether-Lumefantrine (Coartem) AL
6 dose regimen

21. Course of Rx blister packs

22. COARTEM® PREFERENTIAL PRICING FOR PUBLIC SECTOR: EXPECTED PRICE CHANGES BY 2005
PRIVATE SECTOR

23. Artesunate + Mefloquine AS + MQ

24. Artesunate + Amodiaquine AS + AQ

25. Artesunate + sulfadoxine –pyrimethamine – AS + SP

26. Second line Combinations
Artesunate (7 days) + Tetracycline (7)
Artesunate (7 days) + Doxycycline (7)
Artesunate (7 days) + Clindamycin (7) or
4. Quinine in place of AS + any of the above antibiotics for 7 days

27. What to give in pregnancy ?
In 1st trimester
Quinine + Clindamycin 7 days
In 2nd and 3rd trimesters
Any ACT combination as per rec. or
Artesunate + Clindamycin 7 days or
Lactating women same ACT

28. Warning Artemisinins should never be used as monotherapy
Artesunate combinations always given for 3 days; never single dose of AS.
For AL six doses must over 3 days
AQ or MQ or SP should never be used alone - lest drug resistance occurs

29. Combinations not recommended
Chloroquine based combinations (e.g CQ + SP; CQ + Artesunate)
Artesunate (single dose) + SP
Chloproguanil-Dapsone (LapDap)

30. Treatment of severe P.falciparum malaria
Severe malaria is
a medical emergency

31. Complications of falciparum malaria
Coma - cerebral malaria, convulsions
Renal failure – black water fever
Hyperpyrexia, acute pulmonary edema
Hemolytic Jaundice, severe bleeding
Hypovolemic shock, Hypoglycemia
Metabolic acidosis, Coagulopathy,
Severe anaemia, hyperparasitemia

32. Artemisinins parenteral
Artesunate 2.4 mg/kg bw i.v. or i.m. given on admission (time = 0), then at 12 h and 24 h, then once a day is the recommended 1 choice
Artemether 3.2 mg/kg bw i.m. given on admission then 1.6 mg/kg bw per day is an acceptable alternative to quinine i.v infusions
Rectal artemisinins are not as effective

33. Quinine parenteral
A loading dose of quinine of 20 mg salt/kg bw. 10 mg/kg 8th hrly i.v infusion
Rate-controlled i.v. infusion is the preferred route of quinine admin.
If this cannot be given safely, then i.m. injection is a satisfactory alternative.
Rectal admin. is not effective
Quinidine can substitute quinine

34. Trade names Arteether Falcy inj, E Mal inj
Artemether Larether caps, inj
Artesunate Falcigo, Falcynate tab, inj
Mefloquine MQF, Meflotas, Mefque –tab
Quinine Quinarsol, Cinkona inj, tab
SP Pyralfin, Laridox, Amalar
Primaquine Malirid, Primacip, PMQinga

35. AM

36. Momentum is high to ensure access to effective antimalarial treatment
The costs of estimated global ACT requirements far exceeds the current level of ACT financing by the GFA.
An enhancement of the financial resources for purchasing ACTs is, therefore, urgently required to both encourage endemic countries to adopt these effective treatment policies and to control malaria mortality
Malaria is a highly treatable disease, and very effective treatment is available in the form of ACTs. WHO calls on all member countries to unite in a global coalition to enable countries accelerate access to ACTs and make these life-saving medicines affordable to the people in need.

37. The time of poor drugs for poor people is over
Africa has therefore arrived at a critical point in the struggle against a disease that saps its development and kills some 3000 of its children every day. Left to its present course, malaria is a crisis that can only deepen. But if national commitments and global support for the Roll Back Malaria initiative can be translated into action on the ground, then the gains being made by malaria can be reversed.
Unique opportunity to do something about the burden and make an impact on both the health and economic strength of the African region... in light of funding now available through GFATM
And especially in light of the US commitment to AIDS, TB & Malaria (new bill)
The time of poor drugs for poor people is over