Treating malaria

WHO recommendations⁷

As a response to increasing levels of antimalarial resistance, WHO recommends that all countries experiencing resistance to conventional monotherapies, such as chloroquine, amodiaquine or sulfadoxine–pyrimethamine, should use combination therapies, preferably those containing artemisinin derivatives (ACTs – artemisinin-based combination therapies) for falciparum malaria.^{22, 23}

WHO currently recommends the following therapeutic options:

1. artemether/lumefantrine,
2. artesunate plus amodiaquine (In areas where the cure rate of amodiaquine monotherapy is greater than 80%)
3. artesunate plus mefloquine (Insufficient safety data to recommend its use in Africa) artesunate plus sulfadoxine/pyrimethamine (In areas where the cure rate of sulfadoxine/pyrimethamine is greater than 80%)

Note: Amodiaquine plus sulfadoxine pyrimethamine may be considered as an interim option where ACTs cannot be made available, provided that efficacy of both is high.

Since 2001, a total of 56 countries have adopted one of the WHO recommended artemisinin based combination therapies, several as first-line treatment and a few as second-line.

ACT news

Summary of recommendations on treatment for uncomplicated falciparum malaria

Recommendations	Level of evidence
The treatment of choice for uncomplicated falciparum malaria is a combination of two or more antimalarials with different mechanisms of action.	S, T, O
ACTs are the recommended treatments for uncomplicated falciparum malaria.	S
The following ACTs are currently recommended: – artemether-lumefantrine, artesunate + amodiaquine, artesunate + mefloquine, artesunate + sulfadoxine-pyrimethamine.	S, T, O
The choice of ACT in a country or region will be based on the level of          resistance of the partner medicine in the combination:
– in areas of multidrug resistance (South-East Asia), artesunate + mefloquine or artemether-lumefantrine	E
– in Africa, artemether-lumefantrine, artesunate + amodiaquine; artesunate + sulfadoxine-pyrimethamine.	S
The artemisinin derivative components of the combination must be given for at least 3 days for an optimum effect	S
Artemether-lumefantrine should be used with a 6-dose regimen.	T, E
Amodiaquine + sulfadoxine-pyrimethamine may be considered as an interim option in situations where ACTs cannot be made available.	E

(S= formal systematic reviews, such as Cochrane Review, including more than one randomized, controlled trial; T= comparative trials without formal systematic review; O= observational studies (e.g. surveillance or pharmacological data); E= expert opinion/consensus). WHO Guidelines for the treatment of malaria 2006)