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Malaria: an update on treatment of adults in non-endemic countries

BMJ 2006; 333 doi: (Published 27 July 2006) Cite this as: BMJ 2006;333:241
  1. Christopher J M Whitty (, consultant physician1,
  2. David Lalloo, clinical director2,
  3. Andrew Ustianowski, consultant physician in infectious diseases and tropical medicine3
  1. 1 Hospital for Tropical Diseases, Mortimer Market, London WC1E 6AU
  2. 2 Liverpool School of Tropical Medicine, Liverpool L3 5QA
  3. 3 Monsall Unit, North Manchester General Hospital, Manchester M8 5RB
  1. Correspondence to: C J M Whitty

    Every year people die from malaria in Britain and other industrialised countries. Most of these deaths are avoidable: they occur because a patient or doctor has underestimated the severity of the disease or has not considered the diagnosis early enough. This article provides the essential facts on treating malaria in adults in a non-endemic setting and is based on the best available evidence

    Treating uncomplicated falciparum malaria

    The key is to give an effective antimalarial at an appropriate dose and ensure that patients complete the course. Several oral drugs have good activity against falciparum malaria, but drug resistance means that drug combinations are always preferable. Most trials of antimalarials have been conducted in endemic countries where there is at least some immunity to malaria, and this means they may overestimate the efficacy of these drugs in non-immune patients (because patients with immunity tend to clear parasites more readily). There are a few systematic reviews of antimalarials, but most are for drugs that are not appropriate for use in Western countries in non-immune people (such as amodiaquine). Systematic reviews, and in particular meta-analyses, are of limited use for assessing the efficacy of drugs such as antimalarials, for which resistance patterns vary widely both in place and time.

    The Health Protection Agency Advisory Committee on Malaria Prevention for UK Travellers has reviewed the recent data and considers that the best options for treating uncomplicated malaria are:

    • Quinine, either for five days or until the parasites have been cleared from the blood, followed by

    • Doxycycline for seven days or

    • Clindamycin for seven days or

    • Sulfadoxine-pyrimethamine (Fansidar)

    • Artemether-lumefantrine for three days (six dose regimen)

    • Atovaquone-proguanil for three days.

    • Clinical failures can occur with any of these combinations, but failure rates are low if the course is completed. The agency's advice is frequently updated and can be accessed at …

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