Shoklo Malaria Research Unit, Faculty of Tropical Medicine, Mahidol University, Medecins Sans Frontieres, Center for Tropical Medicine, Nuffield Department of Clinical Medicine, John Radcliffe Hospital, Mae Sod, Thailand
Patients with uncomplicated hyperparasitemic falciparum malaria are usually given parenteral antimalarial treatment to prevent a progression to vital organ dysfunction and death. Since the oral artemisinin derivatives are more rapidly effective than other antimalarial drugs, we compared oral artesunate (4 mg/kg/day for three days with mefloquine 25 mg/kg on the second day) with an intravenous quinine loading dose (20 mg of salt/kg initially then 10 mg/kg every 8 hr, followed by mefloquine 25 mg/kg) in an open paired randomized trial in 60 patients with acute falciparum malaria and greater than 4% parasitemia, but no evidence of vital organ dysfunction. There were no deaths and none of the patients progressed to develop severe malaria. Oral artesunate treatment resulted in shorter median [range] times to fever clearance (19 hr [4–45] versus 47 hr [4–107]) (P < 0.0001), parasite clearance (36 hr [18–61] versus 82 hr [36–140]) (P < 0.0001), and discharge from the hospital (25 hr [12–44] versus 58 hr [24–115]) (P < 0.0001). There was no toxicity attributable to artesunate. The cure rates by day 28 were 70% (19 of 27) and 39% (11 of 27) in the artesunate and quinine groups, respectively (relative risk = 1.7; 95% confidence interval = 1.0–3.0). Oral artesunate was simpler, cheaper, safer, and more effective than intravenous quinine for the treatment of uncomplicated hyperparasitemia.