We still need artesunate monotherapyBMJ 2006; 333 doi: https://doi.org/10.1136/bmj.333.7557.45 (Published 29 June 2006) Cite this as: BMJ 2006;333:45
All rapid responses
Nosten et al.,(1) criticize the recent call by the World Health
Organization (WHO) to halt the marketing and use of artemisinin
monotherapy (as a means of delaying the emergence of resistance to
artemisinins) on the grounds that there are specific indications for
Their first is malaria patients with hyperparasitaemia who are at
risk of treatment failure. An artemsinin in combination with a partner
medicine given over 3 days will reduce the parasite biomass as much as
artemisinin monotherapy, reducing the chances of a resistant mutant
emerging. The partner medicine will then eliminate the remaining
parasites, achieving the same results as will an artemisinin monotherapy
intake for 7 days without the added risk of poor patient compliance(2).
Both publications cited by the authors to support their call show that
treatment outcomes of artesunate used in combination with mefloquine are
superior to those of monotherapy.
The second, malaria treatment in pregnancy during the second and
third trimesters, according to WHO (2) may be treated with an ACT, and in
the event of treatment failure, an alternative ACT or quinine+clindamycin.
In selected areas of South-East Asia where quinine sensitivity is low, and
where artemether-lumefantrine and artesunate+mefloquine are not effective,
pregnant women not responding to in pregnancy should be treated with
artesunate combined with clindamycin. In the absence of co-packaged
products, these medicines should be co-administered to the patients.
WHO's call is against the marketing and use of oral artemisinins as
monotherapies and not against their production. For the specific patient
group identified by the authors the solution is co-packaged artesunate
with clindamycin, until new safe and effective fixed-dose ACT combinations
becomes available to treat multi-drug resistant falciparum malaria with.
The large-scale use of oral artemisinins monotherapies, if unabated, will
lead to resistance by endangering the lives of millions of malaria
1. Nosten F, Ashley E, McGready R, Price R. We still need artesunate
monotherapy. British Medical Journal 2006;333:45.
2. WHO. Guidelines for the Treatment of Malaria. World Health
Organisation, Geneva. 2006 (WHO/HTM/MAL/2006.1108).
Competing interests: No competing interests