Malaria is curable if effective treatment is started early because delay in treatment may lead to serious consequences including death. Prompt and effective treatment is also important for controlling the transmission of malaria. A revised National Drug Policy on Malaria has been adopted by the Ministry of Health and Family Welfare, Govt of India in 2010 and these guidelines have been prepared for healthcare personnel involved in the treatment of malaria.

1. PHARMACOTHERAPY OF ANTI-
MALARIAL DRUGS
Dr.Raghavendra S.Hegde, Pharm.D(PB)Dr.Hegde Lectures(DHL)
Role of Community Pharmacist in
Malaria

2. Pharmacotherapy
 Malaria is curable if effective treatment is started early
because delay in treatment may lead to serious
consequences including death.
 Prompt and effective treatment is also important for
controlling the transmission of malaria.
 A revised National Drug Policy on Malaria has been
adopted by the Ministry of Health and Family Welfare,
Govt of India in 2010 and these guidelines have been
prepared for healthcare personnel involved in the
treatment of malaria.
 According to the guideline :

3. (a) Treatment of Uncomplicated Malaria:
 P. vivax cases should be treated with chloroquine in full
therapeutic dose of 25 mg/kg divided over three days.
 In some patients, P. vivax may cause relapse as the
hypnozoites
remain dormant in the liver cells.
 For its prevention, primaquine should be given at a dose
of 0.25 mg/kg body weight daily for 14 days under
supervision.
 All confirmed P. falciparum cases found positive by
microscopy or RDT should be treated with Artemisinin
Combination Therapy (ACT).

4.  This is to be accompanied by single dose primaquine
(0.75 mg/kg body weight) on Day 2.
 ACT consists of an artemisinin derivative
 combined with a long acting antimalarial (amodiaquine,
lumefantrine, mefloquine or sulfadoxine-pyrimethamine).
 The ACT recommended is artesunate (4 mg/kg body
weight) daily for 3 days and sulfadoxine (25 mg/kg body
weight) -pyrimethamine (1.25 mg/kg body weight) on
Day 0.

5.  Presently, fixed dose combinations of
 artemether + lumefantrine
 artesunate + amodiaquine and blister pack of
 artesunate + mefloquine are registered for marketing
in India and are available for use.
 Mixed infections with P. falciparum should be treated as
falciparum malaria.
 However, no relapse, treatment with primaquine can be
given for 14 days, if indicated.

6. Treatment of uncomplicated P falciparum
artemther plus lumefantrine, artesunate plus amodiaquine,
artesunate plus mefloquine, artesunate plus sulfadoxine-
pyrimethamine(ASP) & dihydroartemisin plus piperaquine.
These ACT options are
Artemisinin based combination therapies

7. Treatment of P falciparum in at risk groups
For pregnant women in first trimester quinine and
clindamycin is advised
For pregnant women in the second and trimester,
ACT's are recommended
For lactating women, ACT's are recommended apart
from dapsone, tetracycline and primaquine.

8. Treatment of uncomplicated P vivax
malaria
ACT'S with primaquine for chloroquine resistant
Infections
Chloroquine 25 mg base/kg body weight divided over
three days taken with 0.25 mg base/kg body weight of
primaquine which is taken once daily for 14 days.

9. Treatment of severe malaria
For adults, treatment with artesunate IM injection or IV
infusion
For children, Artesunate IM injection or IV infusion
quinine or artemether.

10.  Dosage schedule for uncomplicated malaria (P. vivax
and falciparum) are provided in revised National
Guidelines for Diagnosis and Treatment of Malaria in
India 2011.
 Oral monotherapy of Artemisinin is banned in India
for uncomplicated malaria because this will lead to
development of resistance.
 Treatment of malaria in pregnancy: ACT should be
given for treatment of P. falciparum malaria in second
and third trimesters of pregnancy, while quinine is
recommended in the first trimester. P. vivax malaria can
be treated with chloroquine.

11. (b) Chemoprophylaxis:
 The chemoprophylaxis is mostly advised for
travelers when planning to travel and stay in
malaria endemic zones/area (Particularly Asia and
Africa).
 Chemoprophylaxis for malaria is as follows :
Doxycycline (Short term chemoprophylaxis, < 6
weeks): 100 mg daily in adults and 1.5 mg/kg
body weight for children more than 8 years old.
The drug should be started 2 days
before travel and continued for 4 weeks after
leaving the malarias area.

12.  Note: Doxycycline is contraindicated in pregnant and
lactating women and children less than 8 years.
 Mefloquine (Long term chemoprophylaxis, >6 weeks): 5
mg/kg body weight (up to 250 mg) weekly and should be
administered two weeks before, during and four weeks
after leaving the area. Mefloquine is contraindicated in
cases with history of convulsions, neuropsychiatric
problems and cardiac conditions.

13. Roles and Responsibilities of Community Pharmacist
 (a) Community Awareness:
 Community pharmacist can play a very important role in
spreading awareness in the locality about:
 Causes and risk of malaria.
 Mosquito bite prevention strategies.
 Importance of prompt diagnosis and treatment, even
 chemoprophylaxis.

14. Prevention Techniques:
 A community pharmacist should spread the message of
various prevention techniques to particularly,
emphasizing personal prophylactic measures to prevent
from bites of mosquitoes.
 Even, he should sensitize community/patient/caregivers
for participating in detection of mosquito breeding places
and adopting strategies for elimination of mosquitoes.
 Malaria FACT CARD is a good tool for consumer
education which should be made available in preferably
local languages.
 The fact card should be simple to understand and focus
important aspects of malaria prevention.

15. Prevention Techniques:
 The information to be passed to educate community are
as follows:
Use a mosquito net or impregnated mosquito net with an
insecticide like pyrethroid
if sleeping outdoors or in an unscreened room.
 The net should be long enough and routinely checked
for holes.
 (i) Cover up bare areas of the body with long-sleeved,
loose-fitting clothing, long trousers and socks if outdoor
after sunset to reduce the risk of mosquitoes biting.

16.  Mosquito repellant creams, oils and Lotion form
(Odomos ") are available in
the market, which can be applied in the bare areas
hands and neck portion to
prevent mosquito bite.
 If any allergic reactions are observed then the
application of
such creams should be immediately stopped.
 (ii) Screen doors, windows and other possible mosquito
entry routes with fine mesh netting.

17.  (iv) Use mosquito coils, liquid vaporizers (Good Knight",
All Out"), mats and sprays which are most popular
household insecticides used to prevent from mosquito
bites.
 (v) Destroy mosquito breeding places around the
habitat.
 (vi) Arrange for indoor residual spraying with insecticide.
 (vii) If symptoms are suggestive of malaria, seek
medical advice.

18. (b) Patient Counseling:
 Related to the disease: A community pharmacist must
clear the concepts of the disease so that a patient can
take full action to prevent its transmission.
 The principle of counseling is based on principles of 5
"A" that are:
ASK: Symptom and duration, breeding of mosquitoes in
the vicinity/locality, use of mosquito nets or means to
prevent mosquito bite.
ASSESS: Non-adherence, understanding of disease
and drugs, concomitant illnesses (cardiovascular,
hepatic and renal failure).

19.  ADVISE: To use mosquito nets, not to allow stale water
logging, to sprinkle kerosene on stagnant water and
other measures to prevent mosquito breeding, complete
full course of
antimalarials (chloroquine, ACT), not to take dose of
antimalarials in empty stomach, take repeat dose of
antimalarials if vomiting occurs within 30 min, to report
back if symptoms do not improve after 48 hrs.

20.  ASSIST: Taking first dose of antimalarials under
observation, managing side effects of
antimalarials, preventing and eliminating mosquito
breeding.
 ARRANGE: Follow-up by setting the next contact with
the physician.
 (ii) Related to drugs: Initial non-specific symptoms of
malaria include fever, sweating and chills, for which the
patient or the care givers first contact the community
pharmacist for
medications for symptomatic relief.

21.  The community pharmacist should be in a position to identify the
malarial clinical presentations and the source of malaria parasite.
 If the patient is having a high grade fever then immediately could
provide an assistance of an antipyretic (paracetamol).
 If the patient comes with a prescription consisting of antimalarial
drugs, then he should counsel regarding administration, side-
effects, monitoring of therapy and importance of adherence to
therapy.
 They should be asked to report the physician/ pharmacist as soon
as side effects are noted. effects and counseling on management
of malaria

22. Counseling regarding antimalarial drug
Antimalarials Side Effects Counseling Emphasis
Quinine (300 mg) Dizziness, ringing in
the
ears, blurred vision
and
tremors, known
collectively
as - Cinchonism
Hypoglycemia,
palpitation,
sweating, weakness.
These symptoms are
not
severe enough to stop
treatment and subside
spontaneously when
administration of the
drugs
ends.

23. Counseling regarding antimalarial drug
Doxycycline (100 mg) Vomiting, diarrhea,
photosensitivity.
Reassure that these
are very
common and
subsides on
continuous usage.
Ask patient to
administer after
1-3 hrs. of
consumption of
antacids, iron and
dairy
products.
Immediately visit a
doctor if allergic
reactions occur

24. Counseling regarding antimalarial drug
Mefloquine, 250 mg Nausea, vomiting,
diarrhea
rash, myalgia
Reassure the patient
and state that this is
very common and
gets subsided on
progressive
Do not take this on
empty
stomach. Ensure that
patient
had eaten before
taking antimalarials.
Arthemether/Lumefan
trine
80 mg/480 mg
Abdominal pain,
headache,
dizziness, anorexia,
fever,
myalgia, insomnia
Atovaquone/Proguani
l
Abdominal pain,
headache,
dizziness, anorexia,
fever,
myalgia, rash

25. Counseling regarding antimalarial drug
Antimalarials Side Effects Counseling Emphasis
Primaquine (7.5 mg.
15 mg)
Vomiting, abdominal
pain,
methaglobinemia
To remember: Risk of
common and
subsides on
continuous usage.
hemolytic anemia in
patients G6PD
deficiency test is a
must
with G6PD deficiency
or
hematologic disease
Reassure that these
are very common and
subsides on
continuous usage.
G6PD deficiency test
is a must to assure
safety.

26. Counseling regarding antimalarial drug
 Currently, chloroquine tablets are available in blister
packs having dosing advises printed on it (Fig. )
 A community pharmacist can provide the dosing
advisory instructions (a component of counseling) as
detailed below:

27. ACT

28. Chloroquine strip containing dosing
advices

29. Chloroquine strip containing dosing advices

30. Counseling on dosing of Chloroquine while
dispensing:
 This drug is effective in treating malaria and commonly prescribed
by doctors.
 Complete the regimen as advised and follow up the physician as
advised.
 1. Take the two tablets at a time as soon as possible. This is the first
dose.
 2. Take this tablet exactly after six hours of the first dose (Day 1).
 3.Do not forget to take this tablet after 24 hours of the first dose
(Day 2).
 4. Complete the regimen by taking this last tablet exactly after 48
hours of the first dose (Day 3)