Table 3.

Summary of treatment drugs for severe malaria in pregnancy

	Quinine		Quinidine	Artesunate	Artemether
Dosage	20  mg salt/kg BW on admission (IV infusion or divided IM injection), then 10 mg/kg BW every 8 ha		6.25 mg base/kg infused IV over 1–2 h, then continuous infusion of 0.0125 mg base/kg/minb	2.4 mg/kg BW or IM at admission then at 12 h and 24 h, then once a daya	3.2 mg/kg BW IM at admission, then 1.6 mg/kg BW per daya
Efficacy	Lower cure rates vs. ART		No data available on efficacy in pregnancy	More efficacious in adults and children than QUI	No data on efficacy in pregnancy; equivalent to QUI in adult populations
Pharmacokinetics	Some studies suggest pregnant women metabolize QUI faster than do non-pregnant women		No data available on pharmacokinetics in pregnancy	Limited data suggest that pregnant women may have accelerated clearance of the metabolite DHA	Pregnant women have lower concentrations metabolite DHA than non-pregnant women; erratic drug release
Tolerability	Mild to moderate cinchonism including tinnitus, headache, blurred vision, altered auditory acuity, nausea, and diarrhea		No data on tolerability in pregnancy	Good tolerability vs. QUI. Some nausea and vomiting but may be due to malaria infection	Good tolerability. Some swelling and pain at injection site
Safety in pregnancy	Safe in pregnancy		Safe in pregnancy	Teratogen in animal studies; limited human studies found no association between exposure and miscarriage, stillbirth, or congenital anomalies	Teratogen in animal studies; limited human studies found no association between exposure and miscarriage, stillbirth, or congenital anomalies
Other serious adverse events	Increased risk of hypoglycemia		Increased risk of QT prolongation requiring electrocardiographic monitoring, hypoglycemia	Delayed hemolysis reported (day 7–31)	None reported; limited data
Interactions with HAART	Women on PIs and NNRTIs need cardiac monitoring due to cardiotoxicity		No data on interactions with HAART	Preferred choice for women on PIs and NNRTIs	When co-administered with PIs or NNRTIs may result in a reduction in the active metabolite of artemether
WHO Recommendation	Recommended to be used in first trimester or in 2nd and 3rd trimester if ART and artemether unavailable		Recommended to be used in the USA;b Not recommended by WHO	Recommended treatment for severe malaria in 2nd–3rd trimester, can be used in 1st trimester	Recommended to be used if ART is unavailable

ART artesunate, BW bodyweight, CDC Centers for Disease Control and Prevention, DHA dihydroartemisinin, HAART highly active anti-retroviral therapy, IM intramuscular, IV intravenous, NNRTI non-nucleotide reverse transcriptase inhibitors, PI protease inhibitor, QUI quinine, WHO World Health Organization

^aTreatment guidelines according to WHO

^bTreatment guidelines according to CDC