Artesunate versus quinine for treatment of severe falciparum malaria: a randomised trial.
BACKGROUND
In the treatment of severe malaria, intravenous artesunate is more rapidly acting than intravenous quinine in terms of parasite clearance, is safer, and is simpler to administer, but whether it can reduce mortality is uncertain.


METHODS
We did an open-label randomised controlled trial in patients admitted to hospital with severe falciparum malaria in Bangladesh, India, Indonesia, and Myanmar. We assigned individuals intravenous artesunate 2.4 mg/kg bodyweight given as a bolus (n=730) at 0, 12, and 24 h, and then daily, or intravenous quinine (20 mg salt per kg loading dose infused over 4 h then 10 mg/kg infused over 2-8 h three times a day; n=731). Oral medication was substituted when possible to complete treatment. Our primary endpoint was death from severe malaria, and analysis was by intention to treat.


RESULTS
We assessed all patients randomised for the primary endpoint. Mortality in artesunate recipients was 15% (107 of 730) compared with 22% (164 of 731) in quinine recipients; an absolute reduction of 34.7% (95% CI 18.5-47.6%; p=0.0002). Treatment with artesunate was well tolerated, whereas quinine was associated with hypoglycaemia (relative risk 3.2, 1.3-7.8; p=0.009).


CONCLUSIONS
Artesunate should become the treatment of choice for severe falciparum malaria in adults.
Dondorp
Arjen
A
Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand.
Nosten
François
F
Stepniewska
Kasia
K
Day
Nick
N
White
Nick
N
D000293:Adolescent; D000962:Antimalarials / Q000627:therapeutic use*; D037621:Artemisinins / Q000627:therapeutic use*; D000077332:Artesunate; D002675:Child, Preschool; D005260:Female; D006801:Humans; D016778:Malaria, Falciparum / Q000188:drug therapy* / Q000401:mortality; D008297:Male; D011803:Quinine / Q000627:therapeutic use*; D012717:Sesquiterpenes / Q000627:therapeutic use*; D015996:Survival Rate
D000962:Antimalarials; D037621:Artemisinins; D012717:Sesquiterpenes; D000077332:Artesunate; D011803:Quinine