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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

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Evidence for artemether/lumefantrine combination for the treatment of imported malaria

We welcome the update on treatment of adult malaria in non-endemic
countries written by Whitty et al (1) since it is ample time to revise
current recommendations. We however believe that choosing quinine as
standard treatment for uncomplicated imported malaria is somewhat old-
fashioned and needs to be seriously questioned. Indeed, this drug leads
almost invariably to severe adverse events, mainly tinnitus and vertigo,
that makes it difficult to bear. Patients are often more sick from the
drug than from the disease itself… The update review does not take into
account the results of the multinational, multicentric clinical trial that
we recently completed using artemether/lumefantrine (Riamet, Coartem) to
treat uncomplicated malaria in non-immune adults.(2) Our results show that
96% of the patients were cured after 28 days of follow-up.

There was no
drug-related serious adverse events. Patients mainly complained of
moderate or mild adverse events, probably related to malaria. As mentioned
by Whitty et al, there is no hope to have sample sizes of imported malaria
large enough to have proper power to demonstrate equivalence with new drug
combinations. Our study with artemether/lumefantrine is the largest
clinical trial ever done in non-immune malaria patients (n=165), and
provides therefore the strongest evidence that this drug combination is
one of the best, if not the best, option to treat malaria in non-endemic
countries in terms of efficacy and safety. For the last three years, we
have been using artemether/lumefantrine for uncomplicated malaria in
Switzerland, both in hospitals and in private practices, and have
encountered very few treatment failures. The same experience has been
recorded in other European countries, especially Germany.

For severe malaria, we were surprised to read that the authors recommend
quinine 10 mg/kg intravenously twice daily. We always use 10 mg/kg three
times a day (every 8 hour), as stated in all textbooks. We would like to
see the evidence for the proposed schedule.

1. Whitty CJM, Lalloo D, Ustianowski A. Malaria: an update on
treatment of adults in non-endemic countries. BMJ 2006;333:241-245.

2. Genton B, Nothdurft HD, Gay F, et al. Open label, multi-center,
non-comparative efficacy, safety and tolerability study of
artemether/lumefantrine in the treatment of acute uncomplicated P.
falciparum malaria in non-immune travelers. Am J Trop Med Hyg 2005; 73: 5.

Competing interests:
B. Genton and C Hatz received research and travel grants from Novartis

Competing interests: No competing interests

10 August 2006
Blaise Genton
Senior lecturer, consultant of tropical diseases
Christophe Hatz
Medical Outpatient Clinic, 1011 Lausanne, Swiss Tropical Institute, 4002 Basel, Switzerland