Transcript Malaria simple by Dr Sarma

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Falciparum Malaria
Dr.R.V.S.N.Sarma., M.D., M.Sc.,
Consultant Physician
Tiruvallur 602 001
Ph: 93805 21221
The Plasmodium species
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P.falciparum
P.vivax
15% of Malaria in India
Commonest in India
P.malariae
P.ovale
Africa and South America
African continent
Why is falciparum
malignant ?
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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
Differentiation of
falciparum
P.falciparum trophozite
P.vivax trophozite
Differentiation of
falciparum
P.falciparum shizont
P.vivax shizont
Differentiation of
falciparum
P.falciparum gametocyte
P.vivax gametocyte
Electron Micrographs
P.falciparum EM
P.vivax EM
Falciparum invading RBC
Mangalore story
Drug Rx. of falciparum
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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
The Anti-malarial Drugs
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Artesunate, Artether, Artemether
Mefloquine, Amodiaquine
Quinine, Chloroquine
Lumefantrine, Halofantrine,
Proguanilchlor (chlorguanide)
Sulfadoxin+Pyrimethmine, Dapsone
Tetracyclines, Doxycyclin, Clindamycin
What is CT ?
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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.
What is ACT ?
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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.
Rationale for ACT
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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
What are Artemisinins ?
Artemisinin derivatives
Dihydroartemesin
Qinghaosu
("ching-how-soo")
Ethyl Ether
Methyl Ether
Arteether
Artemether
Hemisuccinate
Artesunate
Why Artemisinins ?
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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.
ACT - WHO Guidelines
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Technical Consultation on Antimalarial
Combination Therapy: Geneva, April
2001
Guidelines for the treatment of Malaria
WHO document – 266 page book –
February 2006
Treatment of uncomplicated
P.falciparum malaria
Recommended
Combinations
1.
Artemether + Lumefantrine (Coartem)
2.
Artesunate (3 days) + Amodiaquine
3.
Artesunate (3 days) + Mefloquine
4.
Artesunate (3 days) + SP
5.
Amodiaquine + SP (as interim option)
Artemether-Lumefantrine
(Coartem) AL
6 dose regimen
Course of Rx blister packs
COARTEM® PREFERENTIAL PRICING FOR PUBLIC
SECTOR: EXPECTED PRICE CHANGES BY 2005
PUBLIC SECTOR
PRIVATE SECTOR
Artesunate + Mefloquine
AS + MQ
Artesunate + Amodiaquine
AS + AQ
Artesunate + sulfadoxine –
pyrimethamine – AS + SP
Second line Combinations
1.
Artesunate (7 days) + Tetracycline (7)
2.
Artesunate (7 days) + Doxycycline (7)
3.
Artesunate (7 days) + Clindamycin (7)
or
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Quinine in place of AS + any of the
above antibiotics for 7 days
What to give in
pregnancy ?
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In 1st trimester
– Quinine + Clindamycin 7 days
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In 2nd and 3rd trimesters
– Any ACT combination as per rec. or
– Artesunate + Clindamycin 7 days or
– Quinine + Clindamycin 7 days
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Lactating women same ACT
Warning
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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
Combinations not
recommended
1.
Chloroquine based combinations
(e.g CQ + SP; CQ + Artesunate)
2.
Artesunate (single dose) + SP
3.
Chloproguanil-Dapsone (LapDap)
Treatment of severe
P.falciparum malaria
Severe malaria is
a medical emergency
Complications of
falciparum malaria
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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
Artemisinins parenteral
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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
Quinine parenteral
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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
Trade names
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Arteether
Artemether
Artesunate
Mefloquine
Quinine
SP
Primaquine
Falcy inj, E Mal inj
Larether caps, inj
Falcigo, Falcynate tab, inj
MQF, Meflotas, Mefque –tab
Quinarsol, Cinkona inj, tab
Pyralfin, Laridox, Amalar
Malirid, Primacip, PMQinga
AM
Momentum is high to ensure
access to effective antimalarial treatment
1.
The costs of estimated global ACT requirements far
exceeds the current level of ACT financing by the GFA.
2.
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
3.
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 lifesaving medicines affordable to the people in need.